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College  of  $[)2>gtciattg  anb  burgeon* 


Reference  Hifcrarp 


A  TREATISE    OX 

« 

THE    DISEASES    OF    THE 
NERVOUS    SYSTEM 


BY 

WILLIAM   A.   HAMMOND',  M.  D. 

SURGEON-GENERAL  U.  S.  ARMY  (RETIRED  LIST)  ;    LATE   PROFESSOR  OF  DISEASES   OF  THE    MIND  AND 

NERVOCS    SYSTEM     IN    THE     COLLEGE    OF    PHYSICIANS    AND    SURGEONS    OF    NEW   YORK,    THE 

BELLEVUE    HOSPITAL  MEDICAL  COLLEGE,  THE    CNIYERSITY  OF  THE  CITY  OF  NEW  YORK, 

AND   THE    NEW   YORK   POST-GRADCATE    MEDICAL  SCHOOL  AND   HOSPITAL,    ETC. 

WITH  THE  COLLABORATION  OF 

GR^ME    M.    HAMMOND,    M.  D. 

PROFESSOR    OF   DISEASES    OF   THE    MIND    AND    NEHYOUS    SVSTDI    IN    THE    NEW   YORK    POST-GRADUATE 

MEDICAL  SCHOOL  AND   HOSPITAL;    FELLOW  OF  THE   NEW  YORK   ACADEMY  OF   MEDICINE; 

MEMBER    OF    THE    NEW    TORE     NEUROLOGICAL    SOCIETY;     OF    THE 

AMERICAN    NEUROLOGICAL    ASSOCIATION,    ETC. 


WITH  ONE  HUNDRED  AND  EIGHTEEN  ILLUSTRATIONS 


NINTH    EDITION,    WITH    CORRECTIONS     AND    ADDITIONS 


"  Eat  qnoddun  prodlre  tonus,  -<i  dod  dator  ultra."— Horace 


N  BW    Vol;  K 
D.    APPLE  TO  v    AND    COM  PA  N  V 

1891 


Copyright,  187G,  1881,  1886,  1891, 
By    D.    APPLETON    AND    COMPANY. 


PREFACE. 


This,  the  ninth  edition  of  ray  "Treatise  on  Diseases  of  the  Nerv- 
ous System,"  has,  with  the  assistance  of  my  son,  Dr.  Graeme  M.  Ham- 
mond, been  thoroughly  revised  and  brought  up  to  the  present  time. 
The  first  edition  of  the  work  was  published  in  1871,  and  it  has,  there- 
fore, been  for  twenty  years  before  the  medical  profession.  During  that 
time  it  has  continued  to  receive  approval  both  at  home  and  abroad, 
and  has  been  translated  into  the  French,  the  Italian,  and  the  Spanish 
languages.  Several  new  chapters  have  been  added  to  the  present  edi- 
tion, so  that  I  may,  I  think,  confidently  express  the  opinion  that  it  i> 
more  than  ever  worthy  of  the  confidence  which  it  has  hitherto 
obtained. 

William  A.  Hammond. 

Washington,  D.  C,  March  1,  1891. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseondiseas1891hamm 


CONTENTS. 


PAGE 

Introduction, 17 

The  Instruments  and  Apparatus  employed  in  the  Diagnosis  and  Treatment  of 
Diseases  of  the  Nervous  S\ - 
tbical  Reactions,  Normal  and  Pathological,      .        .        .        .28 


SECTION    I. 

DISEASES  OF  THE  BRAIN. 

CHAP. 

I. — Cerebral  Congestion, 32 

Active  Cerebral  Congestion. — Passive  Cerebral  Congestion. 

II.  — Cerebral  An.i.mia 70 

III. — Cerebral  ELbmobbhage, BO 

IV. — Cebebbal  Meningeal  ELbmobbhage 124 

Pachymeningitis  and  Bsematoma  of  the  Dura  Mater, 
V. — Partial  Cebebbal  An.i.miv  bbom  Obliteration  of  Cebebbal 

Blood-Vessels 182 

Thrombosis  of  Cerebral    Arteries. — Embolism  of  Cerebral  Arteries. — 
Thrombosis  of  Cerebral  Veins  and  Sinuses. — Embolism  and  Thrombo- 
r  the  C(  rebral  Capillaries. 
VL— -Cebebbal  Softening,  .... 

VII. — Aphasia,         ...... 

VIII.      A.  i  1 1    CeBEBB  \i.    Mi  mmmtis, 
IX.      ChBOKIC   <  ':  im.i-.i;  \i.    Mi. mm n  D9,     ■ 

Chronic  Verticular  Meningitis. — Chronic  Basilar 

X. — Tl  BSB4  ri  \i;    (   i  i:i  BB  kL    Mi  mm;ii  [8,      . 
XT. — Sipim  i;  \  1 1\  i     ECkOBFHALITIS  OB   (  i  i;i  r.un  is 
Cercbria. 


Meningitis. 


161 
182 

2 1  a 
22 1 

20 1 
259 


10  CONTENTS. 

CHAP.  PAGE 

XII. — Diffused  Cerebral  Sclerosis, 271 

XIII. — Paralysis  Agitans, 282 

XIV. — Tumors  of  the  Brain,       .         . 296 

XV. — Athetosis, 315 

XVI. — Cerebral  Syphilis, 342 

Anatomical  Lesions. — Etiology. — General  Symptomatology. 

XVII. — Symptomatology  of  Cerebral  Lesions, 334 

Cortical  Paralysis. — Paralysis  consecutive  to  Central  Lesions  of  the 
Hemispheres. — Lesions  of  the  Tubercula  Quadrigemina. — Oeulo-Pu- 
pillary  Troubles. — Lesions  of  the  Optic  Tracts. — Lesions  of  the  Cere- 
bral and  Cerebellar  Peduncles. 
XV III. — Symptomatology  of  Cerebellar  Diseases,  ....  348 
Tumors  of  the  Cerebellum. — Haemorrhages  of  the  Cerebellum. — Noth- 
nagel's  Diagnostic  Points. 


SECTION   II. 

DISEASES  OF  THE  SPINAL   CORD. 

I. — Spinal  Congestion, 365 

II. — Spinal  Anaemia, 373 

Anaemia  of  the  Posterior  Columns. — Anaemia  of  the  Antcro-Lateral  Col- 
umns. 
III. — Spinal  Hemorrhage — Spinal  Meningeal  Hemorrhage,       .  406 

IV. — Spinal  Meningitis, 413 

Acute  Spinal  Meningitis. — Chronic  Spinal  Meningitis. 
V. — The  Inflammations  of  the  Spinal  Cord,        ....  429 
Acute  Myelitis. — Infantile  Spinal  Paralysis.— Spinal  Paralysis  of  Adults. 
— Glosso-Labio-Laryngeal  Paralysis. — Progressive  Muscular  Atrophy. 
— Progressive  Facial  Atrophy. — Tetanus. — Sclerosis  of  the  Columns 
of  Turck. — Primary    Symmetrical    Lateral  Sclerosis. — Amyotrophic 
Lateral  Spinal  Sclerosis. — Progressive  Locomotor  Ataxia. — Sclerosis 
of  the  Columns  of  Goll. — Disseminated  Inflammation  of  the  Spinal 
Cord. — Secondary  Inflammation  and  Degeneration  of  the  Spinal  Cord. 
VI. — Non-Inflammatory  Softening  of  the  Spinal  Cord,        .         .611 

Vn. — Tumors  of  the  Spinal  Cord, 616 

VIII. — Syphilis  of  the  Spinal  Cord  and  its  Membranes,         .         .  623 
IX. — Syringomyelia, 626 

X. — PSEUDO-IlYPERTROPniC    PARALYSIS, 629 


CONTENTS.  11 

SECTION  III. 

CEIiEBRO-SriXA  L   DISEASES. 

CHAP.  PAGE 

I. — Hydrophobia, 641 

II.— Epilepsy, 663 

IIT. — Convulsive  Tremor, 698 

IV.— Chorea,          .         .         . 710 

V.— Hysteria, .         .727 

VI. — IIysteboid  Affections, 742 

Catalepsy. — Ecstasy. — Ilystero-Epilepsy. 

VII.  —  Multiple  Cekebro-Spixal  Sclerosis, 770 

VIII.— Paretic  Tremor, 782 

IX.  —  Anapeiratic  PAKAi.vsrs 784 

X. — Exophthalmic  Goitre, 789 


SECTION  IV. 

DISEASES  OF  THE  PERIPHERAL   XERVOUS  SYSTEM. 

I. — Neural  Congestion, 804 

II. — Acute  Neuritis 806 

III.    -Sciatica, 809 

IV. — Multiple  Neuritis 815 

V.  —Chronic  Neuritis— Neural  Sclerosis — Neural  Atrophy,        .  817 

VL — Tumors  of  Nerves 820 

VTI.  — Neural  Paralysis 

Paralysis, — Paralysis  of  Third  Nerve. 

vill.  -  Nm  i;  u.  Spasm 881 

Facial  Spasm.— Torticollis. 

-NEUR  \\.  A\  ESI  ii:  -i  \ 

anaesthesia  '>i  Cutai u  Nerves. — anesthesia  of  the  Fifth  Pair. 

X. — Neural  Hyperesthesia  (Neuralgia),         .... 

Neuralgia  ><r  the  Fifth  Pair  <>f  Nerves. — Cervioo-Oocipital  Neuralgia. — 
Brachial  Neuralgia. — Dorao-Interi  ,— Lumbo- 

A i mI. H n in ;il  Neuralgia. — Crural  Neuralgia. 
XI. — Syphilis  "i   the  Peripheral  Nervous  System,         .        .       .  849 


12 


CONTENTS. 


SECTION   V. 

DISEASES  OF  THE  SYMPATIlETir  NERVOUS  SYSTEM. 

CHAP. 

I.—  Pathology  of  the  Cervical  Sympathetic,  . 
II. — Neuroses  of  the  Cervical  Sympathetic,     . 

Migraine,  or  Ilemicrania. 
III. — Pathology  of  the  Thoracic  Sympathetic,  . 
IV. — Pathology  of  the  Abdominal  Sympathetic, 


PAGE 

.  851 

.  855 


.  863 

.   865 


SECTION   VI. 

CERTAIN  OBSCURE  DISEASES  OF  THE  NERVOUS  SYSTEM. 

I. — Acute  Ascending  Paralysis  (Landry's  Paralysis),      .         .         .  868 

II. — Myxcedema, 870 

ELL— Acromegaly, 878 

IV. — Thomsen's  Disease  (Myotonia  Congenita), 880 

V. — Raynaud's  Disease  (Symmetrical  Gangrene  of  the  Extremities),  882 


SECTION  VII. 

TOXIC  DISEASES  OF   THE  NERVOUS  SYSTEM. 


I. — Plumbism, 

886 

II.  — Alcoholism, 

896 

III. — Bromism,   .... 

915 

IV. — Bydrargism, 

921 

V. — Arsenkism, 

923 

LIST    OF    ILLUSTRATIONS, 


rw. 
I. 
2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 
10. 
11. 

12. 
18. 

14. 
16. 
16. 

17. 

is. 

19. 

ft. 

21. 

22. 
28. 

24. 


Static  Electrical  Machine,     . 

MlLLIAMFEREMETER,      .... 
.LVlIIESIOMETEI:,  .... 

Lombard's  Differential  Calorimeter, 
Lombard's  Thermo-Electric  Pile,    . 
Dynamometer,  .... 

Duchenne's  Trocar,. 

Miliary  Aneurism  of  Brain,  . 

«  it  « 

Atheromatous  Artery  of  Brain,     . 

Diagram    explanatory  of   Paralysis    in    Cams  oi 

Cerebral  Hemorrhage, 
Diagram  explanatory  of  Crossed  Paralysis, 
Cerebral  Arterial  Thrombosis, 

Cerebral  Capillary  Embolism, 

it  tt  tt 

Diagram   explanatory    of   the  Cortical    Lesions 

prooi  cinq  Aphasia, 

Agraphia, 

Dynamooraphic  Tracing  op  Patteni  appeoted  wm 

Paralysis  Agitans, 

Dynamographio  I'rm-im;  op  Patient  lppeoted  wrn 

Paralybi     Loitans, 

U  LLIGNAN1    Ti  KOR   01    Bfl  ON,     .... 
Lnei  RISM  II  Tt  KOI  Of   Bh  on, 
Ham.  oi  Patient  with  Athetosis,  . 

"  after   PhOTOGRAPB  PROM   Dr.  Urn 

HARD, 

Vertical  Be*  no   Brain,  showing  nu  Bit 

iaii"\  oi   the    Lesion  in  the  OriginAI  I 
Athetosis, 


Hammond, 


Bouchard, 

Hammond, 


II  ubiu  r, 
Vtrchow, 


PAQK 

.  20 

.  21 

.  23 

.  25 

.  26 

.  27 

.  28 

.  10? 

.  107 

.  109 

.  113 

.  115 

.  140 

.  158 

.  168 


Modified  from  tfawnyn,     204 


Hammond, 


•l^ 


286 


It 

o/h, 

.  801 

Prof,  II'.  /.'.  Smith, 

.  808 

Hammond^ 

.  817 

From  drawing*   by   Dr. 
to,      . 


14 


LIST   OF   ILLUSTRATIONS. 


FIG. 

25. 

26. 

27. 

28. 
29. 

30. 
81. 
32. 

33. 

34. 
35. 
36. 
37. 

38. 
39. 
40. 
41. 
42. 
43. 
44. 
45. 

46. 

47. 
48. 

49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 


Side  View  of  the  Human  Brain  and  toe  Areas  op 

the  Cerebral  Convolutions,        . 
Horizontal    Section    through  the    Human    Brain, 
showing  the  internal  capsule,  .        .     '   . 

Diagram  of  the  Relation  of  the  Fields  of  Vision, 

Retina,  and  Optic  Tracts, 

Diagram  explanatory  of  the  Crura  Cerebri, 
Patient  with  Probable  Atrophy  and  Sclerosis  of 

Cerebellum, 

Diagram  explanatory  of  the  Medulla  Oblongata, 
Morbid  Anatomy  in  Cervical  Pachymeningitis, 
Deformity  caused  by  Cervical  Pachymeningitis, 
Deformity  caused  by  Chronic  Spinal  Menin- 
gitis,     

Spinal  Cord  in  Infantile  Spinal  Paralysis,  . 


Altered  Nerve-Cells  of  Cord  in  Infantile  Spinal 

Paralysis, 

Muscle  in  Infantile  Spinal  Paralysis, 


Atrophy    of    Muscles    in    Spinal     Paralysis    of 
Adults, 

Atrophy    of     Muscles    in    Spinal    Paralysis     of 
Adults, 

Glosso-Labio-Laryngeal  Paralysis, 

Writing  of  Patient  affected  with    Glosso  Labio 
Laryngeal  Paralysis,         .... 

Glosso-Labio-Laryngeal  Paralysis, 
ii         (i  (i  « 

Progressive  Muscular  Atrophy,     . 


Spinal    Cord  in   Progressive   Muscular   Atrophy 
Progressive  Facial  Atrophy,  .... 
Progressive  Facial  Atrophy,  .... 


Fcrrier, 

Hammond, 

Gowers, 

Modified  from  Gowers, 

Hammond, 

Modified  from  Edincjer, 

Joffroy, 

Charcot, 

Hammond, 
Charcot, 


Hammond, 


Duchenne, 

Friedreich, 

Duchenne, 

Charcot, 

Hammond, 

Lande,   . 


337 

339 

346 
347 

379 
359 
418 
419 

426 
447 
447 

448 

450 
451 
451 
451 
452 
452 
457 
457 

467 

477 
481 

483 
484 
485 
496 
498 
499 
501 
513 
522 
524 
524 
624 


LIST   OF   ILLUSTRATIONS. 


15 


PIG. 

60. 

61. 

62. 

63. 

64. 

65. 

66. 

67. 
68. 
69. 

70. 

71. 
72. 

73. 

71. 


76. 

77. 

78. 

79. 

80. 
81. 
82. 

si. 
86. 


Muscular  Fibre  in  Progressive   Facial   Atrophy 

(Longitudinal  Section — normal),    .... 
Muscular  Fibre  in  Progressive  Facial   Atrophy 

(Longitudinal  Section — abnormal), 
Muscular  Tissue  in  Pro?ressive  Facial   Atrophy 

(Transverse  Section — normal),        .... 
Muscular  Tissue  in  Progressive  Facial  Atrophy 

(Transverse  Section — abnormal),   .... 
Diagram  of  a  Section  of  the  Spinal  Cord  in  the 

Cervical  Region, 

Diagram   explanatory    of   Anaesthesia  in  Lesions 

of  Cord,       

Section  of  Spinal   Cord  in  Sclerosis  of  Lateral 

Columns, 

Section  of  Spinal  Cor.D  in  Lateral  Sclerosis, 

<(  U  u  H  M 

Section  of  Medulla  Oblongata,      .... 

Diagram  representing  the  connection  between 
the  Latkral  Pyramidal  Tract  and  the  Motor 
Cells, 

Deformity  in  Amyotrophic  Lateral  Spinal  Scle- 
rosis,     

Section  through  Medulla  Oblongata  in  Amyo- 
trophic   Lateral  Spinal  Sclerosis,     . 

Writing  ok  Patient  with  Locomotor  Ataxia, 

Dynamograpiiic  Tracing  of  Patient  with  Loco- 
motor Ataxia,      ....... 

Dynamograpiiic  TRACING  Of  Patient  with  Loco- 
motor Ataxia, 

[OB  EXTREMITY  of  Healthy   Humerus,    . 
"  "  Diseased   Hi  mi  i:i  B   01    IV 

tiknt   u  mi    LOCOHOTOB   Atwi  \,   . 

Diagram   BXPLANATOBT   Of  tiii:    Ni:r\  e-Imbres   BNTXB- 

ora  iiik  Coed 

Diagram  e\h.  vsatdry  Of  nu:  CotTBSI  ok  the  Nerve- 
Fibres  in  the  Hiinh.  OoBD,          .          .         .         . 
Section   Of  SPINAL   COBD   in    LOCOHOTOB   A  i  \ xi  v,      . 
[Of    \itvkatus, 

Columns  of  Qoi  i 


Diagram   i:\pi.w\tory  Of  TBI  OONNII  PIONB  BJ 
THE    IfOTOB    TBAOTB    INI)    nil     M :   OXLLB,  , 


Hammond, 

.  528 

u 

.  528 

« 

.  528 

« 

.  528 

Gowers, 

.  532 

Hammond, 

.  534 

Charcot, 

.  553 

« 

.  553 

u 

.  553 

u 

.  553 

Modified  from  Bram  im  //, 

Charcot, 

u 
Hammond) 


554 
558 


(( 

.  578 

( Tunvot, 

.  585 
.  585 

Modified  fron 

' 

Eh 'n </-  r, 

I'i.rr.l, 

.  r.oi 

Hammondf 

.  596 

Pierret, 

u 

u 

it 

.  598 

568 
572 


573 


mm '/.  507 


16 


LIST   OF   ILLUSTRATIONS. 


Syringomyelia, 

Patient  with  Pseudohypertrophic  Paralysis 


FIG. 

87.    TrMOR    OF   THE    SPINAL    CORD, 

88. 

89.  "  " 

90. 

91. 

92. 

93. 

94. 


96. 
97. 
98. 
99. 


100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 

114. 

115. 

116. 
117. 
118. 


Cortical  Substance  of  Brain  in  Hydrophobia, 

Nuclei  of  Pneumogastric  and  Hypoglossal  Nerves 

in  Hydrophobia, 

,  Root  of  Pneumogastric  Nerve  in  Hydrophobia, 

,  Neuroglia-Cells  of  Cord  in  Hydrophobia,  . 

,  Contractions  in  Hysteria,    .... 
ii  (i 

,  Catalepsy  (after  Photograph  from  Dr.  Early), 


Induced  Catalepsy, 
Ecstasy, 
Hysteko-Epilkpsy,  . 


Writing    of    Patient    with    Multiple     Cerebko 

Spinal  Sclerosis, 

Writing    of   Patient   with    Anapeiratic    Paral 

ysis, 

Exophthalmic  Goitre  (after  Photograph  from  Dr 

J.  B.  Crawford), 

Hand  of  Patient  with  Myxedema, 
Portrait  of  Patient  ^  itii  Myxedema,  . 
Diagram    showing   the  Anatomical  Divisions  of 

the  Spinal  Cord, 


Charcot, 

a 

Leyden, 
Van  Gicscn, 
U 

Hammond, 


Charcot, 

u 

Hammond, 

it 

(( 

Bourncville, 

Hammond, 

u 

Charcot, 

Bourncville, 

Hammond, 


640 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


INTRODUCTION. 

THE  IXSTRIMEXTS  AXD  APPARATUS  EMPLOYED  IX  THE  DIAGNOSIS 
AND   THE  ATM  EXT  OF  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diseases  of  the  nervous  system,  like  those  of  the  heart,  lungs, 
and  larynx,  require  special  means  of  investigation  and  treatment.  In 
no  department  of  medical  science  has  progress  been  more  decided  dur- 
ing the  last  decade  than  in  that  class  of  affections  considered  in  this 
treatise,  and  undoubtedly  a  great  deal  of  the  advancement  is  due  to 
the  instruments  and  apparatus  by  which  scientific  research  in  this 
direction  has  become  practicable. 

In  the  present  chapter  I  propose  to  describe  the  instruments  and 
apparatus  employed  in  the  diagnosis  and  treatment  of  diseases  of  the 
nervous  system,  and  to  explain  the  methods  by  which  they  are  used. 

Till:    OPHTHALMOSCOPE. 

The  ophthalmoscope  consists  essential]}  of  a  oonoave  mirror  per- 
forated in  the  centre,  and  of  a  double-convex  lens.  Several  modifi- 
cations of  this  arrangement  are  in  ase,  bul  the  simplest  instrument 

is,  in    my  Opinion,  the   besl    for   ordinary   use,  and    this    is    Liehreielfs  ; 

though,  when  very  great  exactness  i>  required,  as,   for  instance,  in 

determining   tin-   depth   of  an   atrophic   excavation   of    the   optic   disk. 

Dr.  Loring's  ophthalmoscope  is  tar  preferable  t<»  any  other. 

Liebreioh's  ophthalmoscope  consists  of  a  polished  steel  mirror  aboul 
one  and  three-quarters  inch  in  diameter,  concave,  ami  perforated  in 

the    centre    by  a    hole   ahoiit    tin e-t\velt'th    of   an    inch    in    diameter. 

The  edges  of  this  aperture  are  beveled,  so  a-  to  afford  as  little  ob- 
stacle as  possible  to  the  passage  of  the  rays  of   light  to  the  e\.    of  the 

observer. 

The  mirror  is  set  into  a  hron/.e  ring  with  a  handle,  ami  there  is 
attached    also   to   this   ring  a  clip    for    holding  a   concave  ocular  lens, 

which  in  some  conditions  of  refraction,  either  in  the  eye  of  the  \<-.i- 
:* 


18  DISEASES   OF   THE   NERVOUS   SYSTEM. 

tient  or  that  of  the  observer,  is  necessary  in  order  to  produce  the 
requisite  divergence  of  the  parallel  rays  emanating  from  the  pa- 
tient's eye,  and  thus  render  the  image  of  the  fundus  distinct.  A 
direct  image  is  thus  obtained.  The  lamp,  which  should  furnish  a 
steady  flame,  is  placed  on  the  side  of  the  patient's  head  correspond- 
ing to  the  eye  to  be  examined,  and  the  eye  of  the  observer  very 
close  to  that  of  the  patient.  This  process  gives  a  very  satisfactory 
view  of  the  fundus  with  the  optic  disk  and  retinal  vessels,  but  re- 
quires care,  and  is  more  difficult  than  that  by  which  the  inverted  image 
is  obtained. 

In  this  case  the  observer  illuminates  the  fundus  with  the  ophthal- 
moscopic mirror,  and  then  interposes  between  the  mirror  and  the  eye 
a  double-convex  lens  which  he  holds  lightly  between  the  thumb  and 
finger,  resting  the  ring-finger  on  the  forehead  of  the  patient,  so  as  to 
make  the  hand  steady,  the  little  finger  being  disengaged  so  as  to  be 
employed  in  raising  the  eyelid  if  necessary. 

The  object-lens  should  have  a  focal  distance  of  about  two  inches, 
and  it  should  be  held  so  as  to  bring  the  focus  on  the  pupil.  The  lamp 
is  placed  behind  and  a  little  to  one  side  of  the  eye  to  be  examined. 
In  order  to  see  the  optic  disk,  the  patient  is  told  to  look  at  the  ear  of 
the  observer  on  the  side  opposite  to  the  eye  being  examined.  In  this 
way  the  axis  of  vision  is  directed  inward,  and  the  optic  disk  readily 
brought  into  view. 

These  examinations  are  made  in  a  room  lighted  only  by  the  lamp 
used  in  the  processes.  It  is  sometimes  necessary  to  dilate  the  pupil 
with  atropia,  in  order  to  obtain  a  view  of  the  disk,  but  experience  and 
tact  will  generally  enable  the  observer  to  dispense  with  this  rather  dis- 
agreeable procedure. 

Ophthalmoscopic  examinations  require  the  observer  to  possess  a 
very  thorough  acquaintance  with  the  anatomy  of  the  eye,  and  also 
with  the  science  of  optics.  Unless  these  qualifications  are  enjoyed, 
it  will  be  much  better  to  send  the  patient  to  a  competent  ophthalmic 
surgeon  for  an  examination  than  to  rush  to  hasty  conclusions  based  on 
the  most  thorough  ignorance.  The  real  value  of  ophthalmoscopy  in 
diseases  of  the  nervous  system  is  in  danger  of  being  disregarded 
through  the  sciolism  of  pert  pretenders,  who  read  papers  and  write 
memoirs  without  ever  having  seen  the  optic  disk  to  recognize  it. 

Bouchut '  gives  the  following  list  of  abnormal  conditions  which  are 
of  importance  in  the  diagnosis  of  diseases  of  the  nervous  system  : 

Papillary  congestion  ;  peri-papillary  congestion  ;  papillary  anamiia, 
partial  or  general  ;  phlebo-retinal  flexuosities  ;  venous  pulsation  in 
the  retinal  veins  ;  dilatations  of  the  retinal  veins  ;  retinal  varices ; 
phlebo-retinal  haemostases  ;  phlebo-retinal  thromboses  ;  phlebo-retinal 

1  "  Du  diagnostic  des  maladies  du  systeme  nervcux,  par  l'ophthalmoscopie,"  Paris, 
1866,  p.  15. 


INTRODUCTION.  19 

aneurism  ;  haemorrhages  into  the  retina  and  choroid.  The  diseases  in 
which  he  thinks  ophthalmoscopy  is  valuable  as  a  diagnostic  means 
are :  The  several  varieties  of  cerebral  meningitis  ;  cerebral  haemor- 
rhage ;  chronic  encephalitis ;  cerebral  softening ;  meningeal  haemor- 
rhage ;  chronic  hydrocephalus  ;  tumors  of  the  brain  ;  contusion,  com- 
motion, and  compression  of  the  brain  ;  general  paralysis ;  atrophy  of 
the  brain  ;  chronic  myelitis  ;  locomotor  ataxia  ;  tetanus  ;  epilepsy  ; 
essential  convulsions  ;  insanity  ;  and  several  others  of  less  importance. 
To  these  may  be  added  cerebral  congestion,  general  and  partial ; 
cerebral  anaemia  ;  and  the  various  forms  of  sclerosis  affecting  the  brain 
and  spinal  cord. 

ELECTRICAL    APPARATUS. 

The  electrical  apparatus  required  in  the  diagnosis  and  treatment 
of  diseases  of  the  nervous  system  must  be  of  two  kinds  :  one  for 
furnishing  the  primary  or  galvanic  current,  the  other  for  yield- 
ing the  induced  or  faradaic  current.  Among  the  best  machines  of 
the  first  category  are  those  in  which  the  current  is  derived  from 
the  Leclanche,  the  Grenet,  or  the  cbloride-of-silver  cells.  If  the  Le- 
clanche elements  are  preferred,  from  forty  to  one  hundred  cells  arc 
necessary  ;  and  as  these  cells  are  large,  this  form  of  battery  can  only 
be  used  as  an  office  fixture.  For  a  portable  battery,  those  manu- 
factured by  Waite  and  Bartlett,  Jerome  Kidder,  the  Galvano-Fara- 
dic  Company,  and  the  Barrett  Battery  Company,  will  be  found  to 
meet  every  requisite.  The  Barrett  battery  is  especially  adapted  for 
transportation,  as  it  contains  no  fluid.  Portable  batteries  containing 
from  twenty  to  thirty  cells  are  strong  enough  for  almost  all  prac- 
tical purposes. 

Of  faradaic  batteries,  those  manufactured  by  the  firms  previously 
mentioned  leave  nothing  to  be  desired.  Combination  batteries,  fur- 
nishing both  galvanic  and  faradaic  currents,  can  also  be  obtained  from 
these  makers. 

Lately   there   has   been   a   revival   of    Statical    electricity,   and   such 

perfect  instruments  for  its  production  are  being  manufactured  that 
this  form  promises  ere  long  to  come  into  general  use  again.  Fig.  I 
gives  an  excellent  representation  of  the  modern  statical  electric  ma- 
chine.    I  have  witnessed  some  excellent   results  of  its  therapeutical 

power  in  0a8e8  Of  neuralgia,  parahsis,  and  rhctimat  ism. 

Although    the   applications  of   electricity    in    the   treatment    of   dis- 

•  of  the  nervous  system  are  not  so  extensively  useful  as  asserted 
by  nome  authors,  it  is  nevertheless  impossible  for  the  physician  to 
treat  several  affections  of  the  kind  mentioned  without  using  the  agent 
in  some  form  or  other.  This  is  especially  true  of  those  dis<  isee  which 
are  characterized  l>>  paralysis,  in  nearly  all  of  which  electricity  is  use- 
ful.    In  atropine  disorders  it  is  also  indispensable,  and  in  many  bys- 


20  DISEASES   OF   THE   NERVOUS   SYSTEM. 

terical  conditions  it  is  extremely  valuable.  If  only  one  battery  can 
be  procured,  tbe  faradaic  instrument  will  be  found  more  generally 
useful  tban  any  other ;  but,  if  possible,  the  physician  who  intends  to 


treat  to  the  utmost  advantage  diseases  of  the  nervous  system,  should 
possess  one  of  all  three  kinds  mentioned. 


THE    MILLIAMPEEEMETEE. 


This  instrument,  a  representation  of  which  is  given  in  Fig.  2,  is 
used  to  determine  the  rate  of  the  current  flow,  or  the  quantity  of 
electricity  which  passes  through  that  part  of  the  individual  which  is 
included  in  the  circuit  of  the  galvanic  current.  The  milliampere- 
meter  is  a  galvanometer  so  constructed  that  the  deflections  of  the 


INTRODUCTION. 


21 


needle  have  definite  meanings.  Beneath  the  needle  is  a  scale  whose 
divisions  represent  milliamperes,  or  tenths  of  milliamperes.  By  means 
•  of  resistance- 
coils,  which  can  Fl°-  2- 
at  pleasure  be 
included  in  the 
circuit  of  the  in- 
strument, each 
of  the  divisions 
can  be  made 
to  represent  re- 
spectively ten  or 
onehundred  mil- 
liamperes. The 
ampere  is  the 
unit  of  the  cur- 
rent flow  ;  but 
as  a  current  flow 
of  one  ampere 
is  far  too  great 
for  diagnostic 
or  therapeutic 
purposes,  and  as 
an  individual 
could  not  en- 
dure a  current 
of  one  ampere 
unless  the  elec- 
trodes were  of 
enormous  size,  it 
baa  been  found 
necessary  t<>  so 
regulate  the  re- 
sistance of  the  galvanometer  thai  when  a  galvanic  current  is  passed 
through  it  it  will  register  thousandths  <>f  an  ampere,  or  milliamperes. 

The  milliamperemeter  is  as  necessary  i<>  the  physician  who  uses 
galvanism  as  the  graduated  measuring-glass  is  to  the  pharmacist.  It 
enables  him  to  measure  accurately  the  quantity  of  electricity  used. 
He  oan  with  certainty  administer,  day  after  day.  the  same  flow  of 
Current,  and  by  this  means  can  definitely  deft  rmine  whether  the  same 
effects  are  always  produced. 

\\  hen  a  current  <>f  a  certain  number  <>f  cells  is  applied  to  an  indi- 
vidual, it  can  give  n->  accurat.'  idea  <>f  the  flow  of  current  through 
him.     The  resistance  of  individuals  varies  from  daj  to  day;  th 
Bistanoe  in  (he  electrodes  varies  according  t<>  their  degree  of  moist- 


22  DISEASES   OF   THE   NERVOUS   SYSTEM. 

uro  ;  and  the  current  derived  from  the  battery-cells  varies  according 
to  their  condition  of  freshness.  It  can  therefore  he  readily  under- 
stood, as  these  three  factors  are  never  constant,  how  impossible  it  is 
to  pass  the  same  flow  of  current  through  the  same  tissues  at  any  two 
consecutive  trials.  But  if  the  milliamperemeter  is  included  in  the 
circuit,  the  differences  in  the  resistance  of  the  individual  and  the  elec- 
trodes and  the  strength  of  the  cells  need  not  be  considered.  It  is  simply 
necessary  to  include  as  many  cells  in  the  circuit  as  may  be  required  to 
deflect  the  needle  of  the  meter  to  a  certain  point.  At  future  trials, 
when  the  indicator  reaches  the  same  position,  it  signifies  that  the  same 
flow  of  current  is  passing  through  the  tissues,  no  matter  whether  it 
takes  a  greater  or  less  number  of  cells  to  produce  the  desired  result. 

CAUTERIZING    APPARATUS. 

It  is  often  necessary,  in  the  treatment  of  diseases  of  the  nervous 
system,  to  make  use  of  the  actual  cautery  to  the  spine  and  other  parts 
of  the  body.  The  instruments  formerly  employed  were  very  clumsy 
things  made  of  iron,  and,  when  required  for  use,  were  heated  in  a 
furnace  of  some  kind.  Lately  the  Paquelin  cautery,  furnished  with 
platinum  tips  of  such  shapes  as  may  be  required,  and  the  electric  cau- 
tery, have  come  into  general  use. 

OTHER  INSTRUMENTS  AND  APPARATUS. 

Among  the  other  instruments  and  apparatus  required  in  the  diag- 
nosis and  treatment  of  diseases  of  the  nervous  system  are  the  micro- 
scope, the  spbygmograph,  the  stethoscope,  ear-specula,  tuning-forks, 
urinary  test  apparatus  and  chemicals,  hypodermic  syringes,  and  a 
spray  apparatus.  The  latter  is  useful  for  refrigerating  the  skin  over 
the  spinal  column  in  cases  of  chorea  and  other  affections. 

AESTHESIOMETER. 

The  aesthesiometer  is  an  instrument  for  the  purpose  of  determining 
the  degree  of  tactile  sensibility  possessed  by  the  patient.  It  was  de- 
vised in  1858  by  Dr.  Sieveking,1  of  London.  Its  value  in  cases  of 
aberrations  of  sensibility  depends  upon  the  fact,  ascertained  by  Dr.  E. 
H.  Weber,  that  the  capability  of  distinguishing  two  impressions,  made 
upon  the  skin  simultaneously,  varies  in  different  regions  of  the  body 
according  to  the  distance  they  are  apart.  In  sensitive  regions,  as  the 
end  of  the  finger,  the  two  points  of  a  pair  of  dividers  can  be  distin- 
guished at  about  the  twelfth  of  an  inch  apart,  while  in  the  middle  of 
the  back  only  one  point  is  felt,  though  they  are  two  inches  apart.  In 
accordance  with  this  principle,  the  aesthesiometer  is  used  to  determine 
the  sensibility  of  the  skin  in  various  diseases,  it  being  well  known  that 
this  is  subject  to  variation. 

1  British  and  Foreign  Medico-  Chirurgical  Review,  January,  1858,  p.  281. 


INTRODUCTION. 


23 


Fig.  3. 


Thus,  when  the  sensibility  is  intact,  two  points,  touching  the  back 
of  the  hand  at  the  same  time,  can  be  distinguished  as  two  points  when 
separated  an  inch.  If,  in  examining  a  patient,  we  should 'find  that, 
when  the  two  points  were  two  inches  apart,  the  patient  felt  but  a 
single  impression,  we  should  know  that  he  had  lost  sensibility  in  the 
cutaneous  nerves  of  that  part  of  the  body. 

Dr.  Sieveking's  aesthesiomcter  is  nothing  more  than  a  beam-com- 
pass. It  consists  of  a  rod  of  bell-metal  four  inches  in  length,  gradu- 
ated into  inches  and  tenths  of  an  inch.  At  one  end  is  a  fixed  steel 
point  ;  another  steel 
point  is  made  to  slide 
upon  the  beam,  and 
can  be  fixed  at  any 
distance  from  the  first 
by  a  screw  which 
works  at  the  top  of 
the  slide. 

In  1861 '  I  de- 
scribed an  sesthesi- 
ometer  which  I  be- 
lieve was  the  first  used 
in  this  country.  It 
•  (insisted  of  a  pair  of 
dividers,  to  one  arm 
of  which  the  arc  of  a 
circle,  in  brass,  was 
affixed.  This  arc  was 
divided  so  as  to  meas- 
ure tenths  of  an  inch. 
A  short  time  since, 
I     Suggested      to     Mr. 

Stohlman,  the  instrument -maker,  a  modification  of  this  instru- 
ment, which    for  convenience  is,  I  think,  superior  t<>  all    Others.      This, 

as  closed,  for  the  pocket-case,  and  open,  as  in  use,  is  seen  in 
•he  accompanying  woodcut  (Fig.  .'!),'J  and  need  not  be  further  de- 
scribe L 

The  minimum  normal  distances  at  which  the  two  points  of  the 
BBSthesiometer  can  he  distinguished  in  different  regions  of  the  body 
are  stated  in  the  table  oo  the  following  page.1 

1"A  Clinical  Lecture  on  Chronic  Myelitis,"  delivered  in  the  Baltimore  Infirmary, 
Karefa  16,  1861,  American  Mcdioal  Tbmat  Jane  16,  1861,  p.  879. 

•First  described  by  me  in  the  Journal  <>/'  Psychological  Medicine,  October,  I 
p.  830. 

3  This  table  is  quoted  from  Kuller*!  M  Physiology,"  translated  bj  Baly,  London,  1840, 
>.  762, 


24  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Point  of  the  tongue £  a  line. 

Palmar  surface  of  the  third  finger 1        " 

Red  surface  of  the  lips 2  lines. 

Palmar  surface  of  second  finger 2  " 

Dorsal  surface  of  third  finger 3  " 

Tip  of  the  nose 3  " 

The  palm  over  the  heads  of  the  metacarpal  bones 3  " 

Dorsum  of  tongue,  one  inch  from  the  tip 4  " 

Part  of  the  lips  covered  by  the  skin 4  " 

Border  of  the  tongue,  an  inch  from  the  tip 4  " 

Metacarpal  bone  of  the  thumb 4  " 

Extremity  of  the  great-toe 5  " 

Dorsal  surface  of  the  second  finger 5  " 

Palm  of  the  hand 5  " 

Skin  of  the  cheek 5  " 

External  surface  of  the  eyelids 5  " 

Mucous  membrane  of  the  hard  palate 6  " 

Skin  over  the  anterior  surface  of  the  zygoma 7  " 

Plantar  surface  of  the  metatarsal  surface  of  great-toe 7  " 

Dorsal  surface  of  the  first  finger 7  " 

On  the  dorsum  of  the  hand  over  the  heads  of  the  metacarpal 

bones 8  " 

Mucous  membrane  of  the  gums 9  " 

Skin  over  the  posterior  part  of  the  zygoma 10  " 

Lower  part  of  the  forehead 10  " 

Lower  part  of  the  occiput 12  " 

Back  of  the  hand 14  " 

Neck  under  the  lower  jaw 15  " 

Vertex 15  " 

Skin  over  the  patella 16  " 

"           "         sacrum 18  " 

"          "        acromion 18  " 

The  leg,  near  the  knee  and  foot 18  " 

Dorsum  of  the  foot,  near  the  toes 18  " 

The  skin  over  the  sternum 20  " 

"               "       five  upper  vertebrae 24  " 

"              "      spine  near  the  occiput 24  " 

"        in  the  lumbar  region 2-1  " 

"             "     middle  of  the  neck 30  " 

"        over  the  middle  of  the  back 30  " 

The  middle  of  the  arm 30  " 

"              "      thigh 30  " 

THERMOMETER. 

The  thermometer  is  of  use  for  the  purpose  of  determining  varia- 
tions of  temperature  in  different  parts  of  the  body.  It  should  he 
graduated  in  tenths  of  a  degree,  and  be  held  upon  the  part  subject- 
ed to  examination,  so  long  as  the  mercury  continues  to  rise  or  fall. 
Comparative  determinations  must  be  made  under  precisely  similar 
conditions. 


INTRODUCTION. 


25 


BECQUEREL  S    DISKS. 

By  means  of  these  little  instruments  very  slight  variations  of  tem- 
perature can  be  ascertained.  They  consist  of  an  extremely  thin  plate 
of  copper  about  the  size  of  a  half-dime,  soldered  to  a  thin  rod  of  bis- 
muth. This  latter  is  contained  in  a  small  tube  of  hard  rubber  fur- 
nished with  a  handle.  The  disks  are  two  in  number,  and  by  means 
of  delicate  silk-covered  wires  are  in  communication  with  the  poles 
of  a  galvanometer.  If 
a  lower  extremity,  for 
instance,  is  subjected  to 
examination,  one  of  the 
disks  is  placed  upon  it 
and  the  other  upon  the 
corresponding  part  of 
the  other  limb.  If  the 
temperature  of  both 
limbs  be  the  same,  the 
needle  of  the  galvanom- 
eter remains  quiet ;  if 
either  be  warmer  than 
the  other,  the  needle  is 
deflected  to  the  north  or 
south  according  as  one 
or  the.  other  limb  has 
the  higher  temperature. 
By  this  apparatus  very 
much  less  than  the  hun- 
dredth of  a  degree  of 
temperature  can  be  de- 
termined with  absolute 
accuracy.1 


Sic  my    Memoir  on  the  Pathology  and  Treatment  of  Organic  Infantile  Paralysis,1 
in  Journal  of  Psychological  Medicine,  No.  l,  July,  1867,  p. 


26 


DISEASES   OF   TIIE   NERVOUS   SYSTEM. 


Fig.  5. 


dr.  Lombard's  thermo-electric  differential  calorimeter. 

For  determining  differences  of   temperature  nothing  equals  this 
instrument,  both  for  exactness  of  results  and  facility  of  application. 
It  consists,  as  shown  in  the  accompanying  cuts,  of  a  galvanometer 
(Fig.  4)  and  two  thermo-electric  piles  (Fig.  5).     The  needle  of  the 
galvanometer  is  astatic,  and  is  suspended  by  a  deli- 
cate silk  fibre  so  as  just  to  swing  clear  of  the  scale 
it  is  to  traverse.      Above  the  needle  and  outside  of 
the  glass  shade  is  a  magnet  by  means  of  which  the 
needle  is  readily  made  to  point  to  the  zero  of  the 
scale. 

Upon  the  ebonite  plate  to  the  left  of  the  gal- 
vanometer needle  are  the  bobbins  and  four  little  cups 
of  mercury  by  means  of  which  the  connections  are 
made,  and  the  resistance  of  the  thermo-electric  cur- 
rent increased  or  diminished,  according  as  it  is  neces- 
sary to  make  the  needle  more  or  less  delicate  in  its 
indications. 

There  are  two  thermo-electric  piles,  one  of  which 
is  represented  in  Fig.  5,  and  which  for  convenience  of 
manipulation  are  furnished  with  handles.  These  piles 
are  connected  by  their  positive  and  negative  poles, 
and  the  other  positive  and  negative  poles  are  con- 
nected wdth  the  stanchions  seen  on  the  ebonite  plate 
of  the  galvanometer. 

Having  lowered  the  little  metallic  fork  at  the  far- 
ther extremity  of  the  bar  over  the  ebonite  plate  into 
the  cup  of  mercury  immediately  under  it,  the  appa- 
ratus is  ready  for  use.  The  delicacy  is  increased  by 
lowering  one  or  two,  or  all  three  of  the  others,  each 
one  being  in  connection  with  the  bobbin  immediately 
opposite  to  it,  and  which,  when  the  fork  is  out  of  the 
mercury,  is  included  in  the  circuit,  and  hence  has  the  effect  of  in- 
creasing the  resistance.  In  the  figure  all  the  forks  are  represented 
as  down. 

To  make  an  observation,  the  thermo-electric  piles  are  placed  one 
on  the  part  the  relative  temperature  of  which  it  is  desired  to  know, 
and  the  other  on  the  corresponding  sound  part.  If  the  pile  in  con- 
nection with  the  stanchion  nearer  the  corner  of  the  ebonite  plate  is  in 
contact  with  the  hotter  part,  the  needle  will  be  deflected  to  the  north. 
If  the  other  be  the  hotter,  the  needle  will  be  deflected  to  the  south. 
The  extent  of  the  deflection  indicates  the  relative  difference  in  hun- 
dredths of  a  degree  centigrade.  It  is  to  be  remembered  that  the 
instrument  must  be  placed  on  a  firm  table  or  stand,  and  must  be  so 


INTRODUCTION. 


27 


arranged  tbat  the  end  of  the  scale  to  the  right  of  the  cut  points  to 
the  north  ;  the  ebonite  plate  will  therefore  be  at  the  south  end,  and 
the  galvanometer  needle  points  to  the  east.1 

AVith  this  apparatus  of  Dr.  Lombard's  it  is  easy  to  make  relative 
determinations  of  temperature  in  a  minute  or  two,  and  with  great 
exactness  and  delicacy. 

Within  the  past  year  Waite  and  Bartlett  have  manufactured  an 
instrument  equally  as  delicate  as  Dr.  Lombard's  and  much  less  com- 
plicated. 

THE    DYNAMOMETER. 

Several  forms  of  an  instrument  for  measuring  the  strength  of  pa- 
tients have  been  devised.  The  best  and  most  generally  applicable  is 
that  of  M.  Burq,  modified  by  M.  Mathieu,  an  instrument-maker  of 
Paris,  and  still  further  modified  by  me.  It  is  very  simple,  and  for 
ascertaining  the  strength  of  the  hands  leaves  nothing  to  be  desired. 
It  consist  8,  as  is  shown  in  the  cut  (Fig.  0),  of  an  elliptical  steel  spring, 
to  one  end  of  which  is  attached  a  semicircular  metallic  plate,  upon 


Fig.  G. 


which  a  scale  is  marked.  An  indicator,  terminating  at  one  end  in  a 
COg-wheel,  is  capable  of  being  moved  freely  around  the  arc  of  the  cir- 
cle by  a  Steel  arm,  on  one  end  of  which  a  segment  of  a  COg-wheel  is 
attached,  the  COgB  fitting  into   those  of  the  indicator.      The  other  end 

of  the  arm  is  fastened,  by  a  bifurcated  extremity,  to  both  sides  of  the 
i  llipt ical  spring. 

When  the  dynamometer    is    taken    into    the    hand  and    pressed,  the 
two  sides  of    the  Bpring  are  approximated,  and    the  steel  arm  with    (lie 

cogs,  being  poshed  by  both  sides  of  the  Bpring,  turns  the  indicator. 
\\  hen  the  pressure  is  relaxed  the  indicator  returns  to  its  original  posi- 
tion. A  second  indicator,  only  attached  to  the  plate  by  a  spin. lie.  is 
superimposed  upon  the  firsl  one  and  is  carried  around  by  it.  This 
second  indicator, nol  being  connected  with  the  spring,  does  not  return 

1  F<.r  a  fuller  description  <>f  this  Instrument  and  directions  for  it.-  use,  the  read  r  i 
referred  to  the  British  iftdieal  Journal  foi   L87S, 


28  DISEASES   OF  THE   NERVOUS   SYSTEM. 

to  zero,  but  remains  at  the  point  to  which  it  has  been  carried  by  the 
muscular  power  of  the  individual.  We  are  thus  enabled  to  see  the 
extent  of  his  strength,  after  he  has  made  his  effort,  and  do  not  have 
to  watch  him  while  he  is  using  the  instrument.  In  detecting  the 
ability  of  the  operator  to  maintain  a  steady  muscular  pressure  this  in- 
strument is  also  of  service.  Fluctuations  of  the  indicator  determine 
immediately  whether  the  pressure  on  the  spring  is  constant  or  not. 

duchenne's  trocar. 

This  very  useful  little  instrument  is  shown  in  Fig.  7.  It  is  intro- 
duced open  as  at  a.  When  it  has  perforated  the  muscle  under  exam- 
ination, the  small  button  at  the  under  part  of  the  handle  is  pushed 
forward ;  this  propels  a  half-cylinder  of  steel  against  the  shoulder  at 
the  end  of  the  trocar,  and  thus  a  small  piece  of  muscle  is  detached 


Fig.  7. 

<3 


JB_ 


and  caught  in  the  cavity.  The  lower  figure  (b)  represents  the  in- 
strument ready  to  be  withdrawn.  By  drawing  the  button  back,  the 
bit  of  fibre  can  be  taken  out,  and  is  then  ready  for  microscopical 
examination. 


ELECTRICAL   REACTIONS. 

NORMAL  AXD  PATHOLOGICAL. 

In  the  diagnosis  and  treatment  of  diseases  of  the  nervous  system 
both  the  galvanic  and  faradaic  currents  are  indispensable. 

In  a  normal  condition  of  the  muscular  and  nervous  systems  the 
muscles  respond  readily  to  moderate  currents  of  both  of  these  forms 
of  electricity.  If  the  faradaic  current  is  used,  the  muscle  or  muscles 
to  which  the  current  is  applied  contract  with  every  vibration  of  the 
interrupter.  If  the  latter  is  so  arranged  as  to  make  the  interruptions 
slowly,  there  will  be  a  distinct  interval  of  rest  between  the  contractions 
of  the  muscle.  The  more  rapid  the  interruptions,  the  less  interval 
there  will  be  between  the  contractions  of  the  muscle  ;  and,  finally,  if 
the  vibrations  of  the  hammer  are  extremely  rapid,  there  will  be  no  ap- 
preciable period  of  rest  at  all,  and  the  muscle  appears  then  to  be  in  a 


ELECTRICAL   REACTIONS.  29 

continuous  state  of  rigid  contraction.  As  the  current  of  a  faradaic 
battery  is  a  "  to-and-f ro  "  current,  running  first  in  one  direction  and 
then  in  the  other,  it  follows  that  normal  muscular  tissue  must  respond 
instantly  to  these  rapid  changes  of  current  in  order  to  continue  in  a 
constant  state  of  rigidity.  In  many  forms  of  paralysis  this  ability  to 
respond  to  a  rapidly  vibrating  current  is  lost.  It  is  therefore  advisa- 
ble, in  procuring  a  faradaic  battery,  to  obtain  one  which  admits  of  both 
fine  and  coarse  interruptions.  If  the  galvanic  current  is  used,  it  will  be 
observed  that  the  muscle  to  which  it  is  applied  only  contracts  at  the 
"  making"  and  at  the  -'breaking"  of  the  circuit,  or  when  the  strength 
of  the  current  is  suddenly  changed.  While  the  current  is  continuous 
the  muscle  remains  quiescent.  The  same  results  are  obtained  whether 
the  electrical  applications  are  made  to  the  nerves  or  to  the  muscles. 

The  two  poles  of  a  battery  are  known  as  the  anode  or  positive,  and 
the  cathode  or  negative. 

In  testing  the  electrical  reactions  of  a  muscle,  one  electrode,  the 
sponge  surface  of  which  should  be  at  least  two  inches  in  diameter, 
should  be  placed  on  some  indifferent  part  of  the  body,  such  as,  for  in- 
stance, the  sternum,  or  the  skin  over  some  portion  of  the  spine.  The 
oilier  electrode  should  be  much  smaller  and  must  be  provided  with  an 
"interrupting  handle."  This  electrode  is  to  be  applied  directly  to  the 
motor  points  of  the  muscles  which  are  to  be  tested.  By  means  of  a 
"pole-changer"  attached  to  the  battery  either  electrode  can  be  made 
cathode  or  anode  at  pleasure. 

In  individuals  in  a  normal  state  of  health  muscular  contraction, 
under  the  stimulation  of  the  galvanic  current,  follows  definite  laws. 

If  the  weakest  current  is  employed  that  will  cause  a  muscular  con- 
traction, it  is  found  to  take  place  when  the  negative  pole  is  applied  to 
the  muscle  and  the  circuit  is  then  closed.  This  is  termed  the  cathodal 
closure  contraction,  and  is  designated  by  the  letters  C.C.C.  or  K.C.C. 

If  the  current  is  increased  in  Btrength,  the  cathodal  closure  contrac- 
tion will  be  Stronger,  and  there  will  also  be  a  slight  contraction  if  the 
pole  <>n  the  muscle  is  made  the  anode  and  the  circuit  is  suddenly 
closed.  This  latter  is  known  as  the  anodal  closure  contraction,  and  is 
represented  by  the  letters  A.C.C.  With  increased  Btrength  of  current 
w  are  enabled  to  obtain  the  anodal  opening  contraction,  A. <>.('.,  and 

the  cathodal  Opening  contraction,  ('.().('.  or  K. ().('.      h   will    therefore 

be  observed  thai  in  health  the  cathodal  closure  contraction  is  greater 
'han  the  anoda]  closure  contraction,  and  the  anodal  opening  contrac- 
tion is  greater  than  the  cathodal  opening  contraction. 

The  normal  reactions,  therefore,  assuming  that  a  sufficiently  pow- 
erful current  is  employed,  are  as  follow-  ; 

I.  C.C.C.    2.  A.c.c.    :;.  A.O.C.     I.  C.O.C. 
When  degenerative  changes  occur  in  the  motor  nerves  or  in  the 

motor  cells  in  the  anterior  horn  of  gray  inattt  r   in   the  spinal  cord,  the 


30  DISEASES   OF   THE   NERVOUS   SYSTEM. 

normal  reactions  both  to  faradism  and  to  galvanism  change  materially. 
These  changes  have  been  termed  the  "  reactions  of  degeneration  "  by 
Erb,  who  first  described  them.  The  reactions  of  the  nerves  and  mus- 
cles differ,  and  must  therefore  be  considered  separately. 

When  the  motor  nerves  are  the  seat  of  a  degenerative  process  the 
reaction  of  the  nerve  to  both  faradaic  and  to  galvanic  currents  de- 
creases proportionately  as  the  degeneration  increases,  and,  if  the  dis- 
ease is  not  arrested,  all  excitability  disappears  in  about-  two  weeks' 
time.     This  is  termed  "quantitative  degeneration." 

The  muscular  contractility  also  undergoes  quantitative  degenera- 
tion. The  rapidly  interrupted  faradaic  current  fails  to  contract  the 
muscles  at  all,  but  a  slowly  interrupted  current  will  for  a  few  days 
induce  slight  contractions.  The  reaction  to  the  galvanic  current  also 
gradually  decreases. 

At  the  end  of  about  the  first  week  "  qualitative"  degenerations  can  be 
obtained.  It  will  then  be  observed  that  the  cathodal  closure  contraction 
has  either  diminished  considerably  or  else  has  disappeared  altogether, 
while  the  anodal  closure  contraction,  which  was  formerly  insignificant, 
now  takes  precedence  over  all  others.  Frequently  the  cathodal  and  ano- 
dal opening  contractions  cannot  be  obtained  at  all,  but  if  they  can  be  it 
will  be  observed  that  the  cathodal  opening  contraction  is  the  stronger. 

Comparing  the  normal  polar  reactions  with  those  obtained  where 
disease  of  the  motor  nerve  exists,  we  note  the  following  difference : 
In  health  :    1.  C.C.C.     2.  A.C.C.     3.  A.O.C.     4.  C.O.C. 
In  disease:    1.  A.C.C.     2.  C.C.C.     3.  C.O.C.     4.  A.O.C. 

Sometimes  the  polar  degenerative  reactions  are  not  so  well  marked. 
In  a  few  instances  it  will  be  observed  that  the  anodal  closure  contrac- 
tion equals  but  does  not  excel  the  cathodal  closure  contraction.  In 
that  case  the  reactions  are  written  as  follows  : 

A.C.C.  =  C.C.C.  and  C.O.C.  =  A.O.C. 

If  the  degeneration  of  the  nerve  advances  till  it  is  completely  de- 
stroyed, the  polar  degenerative  reactions  gradually  fail  quantitatively 
and  eventually  disappear  in  the  reverse  order  to  that  in  which  they 
are  obtained.  That  is,  the  first  to  be  lost  will  be  the  anodal  opening 
contraction,  then  the  cathodal  opening  contraction,  then  the  cathodal 
closure  contraction,  and  finally  the  anodal  closure  contraction. 

If  the  destruction  of  the  nerve  is  not  completed  and  if  regenera- 
tion ensues,  the  electrical  reactions  gradually  return  to  their  normal 
condition.  If  a  nerve  has  been  so  injured  that  it  can  not  transmit  vo- 
litional motor  impulses,  and  even  electrical  excitation  fails  to  induce 
muscular  contractions,  and  then  recovery  takes  place,  it  will  be  found 
that  the  muscles  respond  to  the  will  some  time  before  they  will  react 
to  any  form  of  electrical  irritation. 

When  the  anterior  horn  of  gray  matter  in  the  spinal  cord  is  dis- 
eased so  that  the  motor  cells  are  involved,  there  is  paralysis. 


ELECTRICAL   REACTIONS.  31 

Within  three  days  after  the  paralysis  appears  it  will  be  found  that 
electrical  excitation  applied  to  the  motor  nerves  which  spring  from 
the  diseased  area  fails  to  produce  strong  muscular  contractions,  and 
that,  as  the  disease  progresses,  the  excitability  of  the  nerve  gradually 
diminishes  to  both  forms  of  current  till  in  about  two  weeks'  time  it 
is  abolished  altogether. 

The  degenerative  reactions  observed  in  the  muscular  system  must 
not  be  confused  with  those  obtained  by  electrically  exciting  the  nerve. 

The  muscles  which  receive  their  motor  energy  from  the  diseased 
segment  of  the  cord  soon  lose  their  contractility  to  the  faradaic  current. 
At  first  a  slowly  interrupted  current  will  induce  contractions,  but  at 
the  end  of  two  weeks  from  the  beginning  of  the  paralysis  the  strong- 
est current  that  the  individual  can  beaf  is  devoid  of  any  motor  effect. 
The  galvanic  excitability  decreases  slowly  for  a  few  days  and  then  grad- 
ually increases  until  a  slight  current,  which  in  the  normal  state  would  not 
induce  any  appreciable  muscular  movement,  is  observed  to  be  followed 
by  strong  contractions.  With  this  quantitative  increase  the  qualitative 
polar  reactions  make  their  appearance  in  the  same  manner  as  when  the 
nerve  was  the  seat  of  disease.  The  cathodal  closure  contraction  de- 
clines, the  anodal  closure  contraction  is  augmented,  and  the  cathodal 
opening  contraction  takes  precedence  over  the  anodal  opening  contrac- 
tion. As  the  disease  advances  and  the  muscles  undergo  atrophy  there  is 
the  same  quantitative  decline  in  the  contractions  that  is  seen  when  the 
nerve  is  completely  degenerated  ;  and,  finally,  when  the  contractile  ele- 
ments of  the  muscles  have  been  entirely  absorbed  no  contractions  can 
be  obtained  from  any  strength  of  current.  As  in  cases  of  degeneration 
of  the  nerve,  the  anodal  closure  contraction  is  the  last  to  disappear. 

When  paralysis  follows  from  cerebral  disease  and  there  is  no  de- 
generation of  the  muscles,  of  the  motor  nerve  supplying  the  muscles. 
Of  of  that  portion  of  the  spinal  cord  from  which  the  motor  nerves 
arise,  the  electrical  reactions  will  be  found  to  be  normal. 


SECTION  L 
DISEASES    OF   THE    BRAIN". 


CHAPTER  I. 

CEREBRAL    CONGESTION. 


Cerebral  congestion  is  of  two  kinds,  which  differ  as  regards  their 
mode  of  origin  and  symptoms.  In  the  active  form,  there  is  an  increase 
in  the  amount  of  arterial  blood  circulating  in  the  vessels  of  the  brain  ; 
in  the  passive,  the  quantity  of  venous  blood  is  augmented.  Occasion- 
ally the  two  conditions  coexist. 

ACTIVE    CEREBRAL    CONGESTION. 

This  is  much  the  more  common  form.  Of  the  cases  recorded  in 
my  note-book,  as  occurring  in  my  private  and  hospital  practice,  over 
five-sixths  were  of  this  description. 

Audral,  who,  however,  failed  to  distinguish  the  first  or  hyperaemic 
stage,  recognized  eight  varieties,  all  of  which  may  with  advantage  be 
comprehended  in  six,  which  are  appropriately  designated  from  the 
chief  feature  characterizing  the  attack,  namely,  the  apoplectic,  the  par- 
alytic, the  convulsive,  the  soporific,  the  maniacal,  and  the  aphasic,  the 
latter  being  a  sixth  form,  which  is  now  for  the  first  time  systematic- 
ally arranged  in  the  present  category.  It  will  doubtless  be  the  case 
that,  as  our  knowledge  of  the  functions  of  the  brain  becomes  greater, 
other  forms  of  cerebral  congestion,  especially  those  of  a  partial  charac- 
ter— like  the  aphasic,  for  instance — will  be  recognized.  Among  these 
will  be  various  sensory  and  motor  disturbances,  and  perhaps  also  ab 
errations  of  mentality.  For  the  present,  however,  it  is  perhaps  better 
to  defer  considering  these  conditions,  as  often  being  instances  of  local- 
ized congestion,  till  the  science  of  brain  localization  is  more  completely 
established. 

Any  of  those  may  occur  with  scarcely  a  moment's  warning.  Gen- 
erally, however,  there  is  a  premonitory  or  first  stage,  the  symptoms  of 


CEREBRAL   CONGESTION.  33 

which,  though  well  marked,  are  not  peculiar,  exclusively,  to  any  one  of 
the  fully  established  conditions  mentioned.  It  is  therefore  impossible 
to  predict  with  accuracy,  from  the  symptoms  of  this  prodromatic  stage, 
whether  the  apoplectic,  the  paralytic,  the  convulsive,  the  soporific,  the 
maniacal,  or  the  aphasic  form,  will  be  developed.  An  attentive  study 
of  this  stage  should  always  be  made,  and  active  measures  taken  for  the 
relief  of  the  patient  at  a  time  when  success  can  generally  be  obtained. 

Symptoms.     First  Stage  (Cerebral  Hyperemia). 

Among  the  earliest  symptoms  of  active  cerebral  congestion,  wake- 
fulness is  especially  noticeable,  and  may  be  for  a  time  the  only  evidence 
of  disorder  which  attracts  the  attention  of  the  patient.  He  goes  to 
bed  feeling  weary,  and  as  if  sleep  would  very  quickly  overtake  him, 
but  he  is  disappointed,  for  he  obtains  but  an  hour  or  two  of  disturbed 
slumber,  which  is  generally  broken  by  unpleasant  dreams.  During 
the  remainder  of  the  night  he  tosses  restlessly  from  side  to  side  of  the 
bed,  his  mind  either  occupied  by  the  thoughts  which  have  occurred  to 
him  through  the  day,  or  else  filled  with  the  most  preposterous  ideas. 
He  consequently  rises  unrefreshed,  feverish,  and  ill  prepared  for  either 
mental  or  physical  exertion.1  So  far  as  the  mind  is  concerned,  there 
is  an  inability  to  give  the  attention  to  any  subject  requiring  much 
thought,  and  at  times  an  absolute  want  of  power  to  get  correct  ideas 
of  even  .simple  matters.  This  is  especially  seen  in  those  who  have  arith- 
metical questions  to  solve,  or  long  columns  of  figures  to  add  up.  In- 
deed, mental  labor  of  all  descriptions  is  not  only  difficult,  but  is  irk- 
some in  the  extreme. 

Before  long  the  evidences  of  intellectual  derangement  become  more 
evident.  The  ideas  are  confused  and  without  logical  arrangement  ; 
the  memory  begins  to  fail,  especially  in  regard  to  recent  ocourrenoes  ; 
and  there  Beems  to  be  a  special  proclivity  to  forget  words,  and  to  sub- 
stitute others  having  a  similar  sound  when  pronounced,  or  appearance 

when  written.  The  names  of  persons  and  places  are  particularly  diffi- 
cult to  recollect  The  judgment  is  weak  and  vacillating ;  the  most 
strongly  expressed  determination  is  changed  apparently  without  rea- 
son, and  again  there  may  be  an  impossibility  of  arriving  at  a  decision 

in  cases  where  ordinarily  hut  little  reflect  ion  v.  ould  be  necessary.  Any 
effort   toward  continuous  or  severe  thought    increases  the  difficulties  of 

the  mind,  ami  augments  the  pain  or  uneasiness  which  generally  exists 
in  the  head.     Illusions,  hallucinations,  or  delusions  maj   be  present, 

but    are   not    usually    fixed;   and    the    patient    will    often    laugh    at    the 

absurd  images  he  lias  seen,  or  ideas  he  has  entertained,  not  five  min- 
utes before.     Persons  thus  affected  will  frequently  reason  clearly  in 

regard  to  apparitions  «.r  roices,  of  the  unreality  of  w  hich  they  arc  fully 

sensible. 

1  For  a  more  coinj.lrtc  a nut  of  wakefulness  in  nil  its  relations,  sco  tii''  anfhort 

treatise  on  "Bleep  and  its  Dcran:  J.  B,  Uppinoott  .^  <'<>..  Philadelphia,  1870. 

4 


34  DISEASES   OF   THE   BRAIN. 

A  condition  very  often  present  is  a  morbid  apprehension  of  im- 
pending evil,  for  which  there  is  no  assignable  cause,  and  the  nature  of 
which  the  patient  can  rarely  define.  He  is  sure  something  will  happen 
to  hira,  but  what,  he  does  not  know  ;  or,  if  he  does  designate  the  form 
of  trouble  to  ensue,  he  changes  from  one  kind  to  another  without  any 
more  reason  than  he  had  for  the  erroneous  idea  in  the  first  place. 
Again,  he  is  afraid  that  he  may  do  some  injurious  act  either  against 
himself  or  others,  and  is  hence  fearful  of  being  left  alone.  One  patient 
was  afraid  to  cross  the  ferry  from  Brooklyn  lest  he  might  be  tempted 
to  throw  himself  off  the  boat  ;  another  kept  away  from  railway  tracks, 
fearing  that  he  might  be  led  by  the  sight  of  a  passing  train  to  put 
himself  in  the  way.of  the  engine  ;  another  begged  his  wife  to  lock  up 
his  razors  ;  and  another  would  not  take  a  warm  bath,  under  the  appre- 
hension that  he  might  neglect  to  turn  off  the  hot  water  in  time.  It 
would  be  easy  to  enumerate  very  many  more  like  instances.  They 
remind  us  of  "  morbid  impulse,"  but  the  subjects,  unlike  those  of  this 
last-named  condition,  never  yield  to  the  excitation.  In  fact,  it  is 
not  an  impulse,  but  the  fear  of  an  impulse,  by  which  they  are  influ- 
enced. 

The  emotioned  system  participates  in  the  general  mental  disturbance, 
and  indeed  is  often  the  part  of  the  mind  most  prominently  deranged. 
The  passions  are  easily  roused  into  activity  by  slight  exciting  causes  ; 
trifling  circumstances  produce  great  annoyance,  and  the  little  every- 
day troubles  of  life  appear  of  vast  importance.  The  disposition  accord- 
ingly becomes  suspicious,  peevish,  and  fretful.  Persons  thus  affected 
are  very  far,  ordinarily,  from  being  pleasant  companions.  Many  of  them 
avoid  social  intercourse,  and  shut  themselves  up  in  their  rooms  to  brood 
over  their  real  and  imaginary  disorders.  Others,  again,  plunge  into 
dissipation  and  excesses  of  every  kind,  in  the  vain  expectation  of  being 
able  by  such  means  to  overcome  the  disease  ;  and  again  others  strive, 
by  a  constant  change  of  one  physician  for  another,  or  the  substitution 
of  one  quack  medicine  for  another  equally  quackish,  to  get  relief  from 
their  mental  and  physical  distress.  In  some,  there  are  very  few  de- 
cided symptoms  present,  except  the  inability  to  sleep,  and  the  inca- 
pability of  concentrating  the  mind  upon  an  object  of  study  or  labor, 
without  inducing  pain  or  discomfort  of  some  kind  in  the  head. 

In  all,  however,  there  is  the  same  mental  introspection.  Every 
symptom  is  exaggerated  ;  and,  if  one  with  which  the  patient  has  suf- 
fered should  happen  to  be  absent,  he  is  dissatisfied  till  it  makes  its 
appearance  again,  or  till  he  has,  by  concentration  of  his  mind  on  the 
subject,  brought  it  back,  and  with  it  an  aggravation  of  all  the  other 
phenomena.  "  Doctor,"  said  a  gentleman  to  me  a  few  days  since,  "  I 
am  afraid  I  am  getting  worse,  for  last  night  I  slept  several  hours,  and, 
if  stupor  should  set  in,  I  suppose  it  would  be  bad."  Another,  who 
had  for  several  months  suffered  from  an  almost  pei*petual  pain  in  the 


CEREBRAL   CONGESTION.  35 

head,  was  quite  sure  sensibility  was  being  destroyed  when  he  found 
himself  a  whole  day  without  it. 

This  fixing  of  the  attention  upon  the  body  is  of  course  apt  to  de- 
velop symptoms  which  would  otherwise,  doubtless,  never  make  their 
appearance  ;  and  scarcely  a  day  passes  that  instances  in  point  do  not 
come  under  my  observation.  The  experiments  of  Mr.  Braid  in  this 
direction  are  very  instructive,  and  will  bear  quotation  in  the  present 
connection.  He  requested  four  gentlemen,  whose  ages  varied  from 
forty  to  fifty-six  years,  and  who  were  in  good  health,  to  lay  their 
hands,  palms  upward,  on  a  tabje,  and  to  look  at  them  fixedly  for  a 
few  minutes.  They  were  not  to  speak,  but  were,  as  far  as  possible,  to 
concentrate  the  attention  on  the  upturned  palms,  and  to  await  the 
result.  In  about  five  minutes  one  of  these  gentlemen,  a  member  of 
the  Royal  Academy,  said  that  he  felt  a  sensation  of  great  cold  in  the 
hand  ;  another,  an  author  of  distinction,  said  that  at  first  he  thought 
nothing  was  going  to  happen,  but  at  last  he  felt  a  darting,  pricking 
sensation,  as  if  electric  sparks  were  being  drawn  from  the  hand  ;  the 
third,  late  mayor  of  a  large  city,  reported  that  he  felt  a  very  uncom- 
fortable sensation  of  heat  come  over  the  hand  ;  and  the  fourth,  secre- 
tary to  an  important  association,  had  become  rigidly  cataleptic,  the 
arm  being  firmly  fixed  on  the  tabic1 

Speaking  of  this  subject,  Sir  Henry  Holland  *  says  : 

"  One  limb,  for  instance,  or  even  a  single  finger,  or  a  portion  of  the 
sentient  surface  of  the  body,  may  be  taken  for  observation,  and  the 
results  tested  and  checked  by  means  wholly  independent  of  the  subject 
of  experiment,  a  point  often  very  important  to  the  truth  of  the  result. 

"  We  have  here,  as  in  other  parts  of  the  inquiry,  to  look  to  the 
respective  rases  of  attention  directed  by  express  volition,  or  suggested 
by  some  outward  cause  acting  on  the  mind.  In  the  former  and  more 
simple  case,  if  a  limb  be  taken  for  experiment,  a  peculiar  sense  of 
weight  with  a  vibratory  tingling,  or  sensations  approaching  to  cramp, 
are  produced  by  the  consciousness  concentrated  upon  it.  It  is  difficult 
to  describe  by  words  feelings  of  this  nature,  evanescenl  or  changing 
at  each  moment,  and  dilVcivnt  doubtless  in  different  persona  ;  but 
probably  the  closest  resemblance  is  to  those  produced  in  ordinary  cases 
by  muscular  fatigue  or  stagnant  circulation  through  the  limb.  There 
is  reason,  indeed,  to  suppose  that  the  muscular  structure  is  actually 
affected  in  these  cases,  and  frequently  even  by  particular  conditions  of 
movement,  though  not  volitional  in  kind." 

Medical  men  are  said,  and  doubtless  with  truth — as  many  oases  will 
occur  to  the  mind  of  the  professional  reader    to  be  particularly  liable 

1  For  many  illustrations  of  the  power  of  the  attention  over  the  body,  the  reader  Is 
referred  to  the  author's  "  Spiritualism,  and  Allied  Causes  and  Conditions  of  Nervon  De 
rangetnent.'1     New  VipiU  ;    i 

I,"  Chapters  on  llental  Physiology,"  p.  24.     London:  1852. 


36  DISEASES   OF   THE   BRAIN. 

to  be  affected  with  the  diseases  to  which  they  have  given  special  atten- 
tion ;  and  every  winter,  during  my  course  of  lectures  on  the  nervous 
system,  I  am  consulted  by  medical  students,  who  imagine  themselves 
to  be  the  subjects  of  the  diseases  I  have  brought  to  their  notice  ;  and 
in  some  cases  with  reason.  Under  another  division  of  the  subject,  I 
shall  have  occasion  to  return  to  this  matter  for  further  consideration. 

It  follows  from  what  has  been  said,  that,  if  well  persons  are  liable 
to  contract  diseases  through  mental  concentration,  the  subjects  of 
cerebral  hyperemia  must  be  peculiarly  prone  to  the  extension  of  their 
morbid  symptoms  through  a  like  influence,  and  in  fact  this  is  exactly 
what  occurs.  A  slight  accidental  sensation  in  some  part  of  the  body 
engages  the  attention,  and  becomes  a  fixture  in  the  clinical  history  of 
the  patient.  Neuralgic  pains,  numbness,  spasm,  and  even  paralysis, 
may  be  thus  induced,  to  say  nothing  of  functional  disturbances  of  the 
several  organs. 

Under  this  latter  head  there  is  none  more  frequently  met  with  than 
what,  for  a  want  of  a  better  name,  may  be  called  false  impotence.  To 
the  production  of  this  condition,  the  erroneous  ideas  which  prevail  re- 
lative to  spermatorrhoea,  and  the  fears  excited  by  the  advertisements 
and  books  of  unprincipled  quacks,  largely  contribute.  Indeed,  it  is 
rarely  the  case  that  a  male  patient  affected  with  cerebral  hyperemia 
does  not  at  some  time  or  other  of  its  course  imagine  that  he  is  impo- 
tent, and  the  only  grounds  he  has  for  this  notion  are  the  facts  that  he 
has  an  occasional  nocturnal  emission,  or  the  exudation  of  a  little  ure- 
thral mucus  under  the  influence  of  sexual  excitement.  Still  the  fact  is 
not  to  be  overlooked  that  the  predominance  of  this  idea  is  extremely, 
prejudicial  to  the  patient's  well-being,  and  it  is  therefore  important 
that  the  physician  should,  by  obtaining  his  confidence  and  enlightening 
his  ignorance,  dispel  the  delusion  at  the  earliest  possible  moment. 

In  addition,  there  are  certain  physical  symptoms  of  disordered  cere- 
bral action  which  by  their  prominence  force  themselves  into  notice. 
Thus  there  are  pain,  heat,  a  feeling  of  fullness  or  of  distention  in  the 
head,  the  sensation  as  if  a  tight  band  encircled  it,  or  the  impression  of 
a  dragging  or  clawing  character  at  the  vertex.  Vertigo  is,  however, 
the  most  prominent  of  all  this  category  of  phenomena  in  the  majority 
of  cases,  and  may  be  so  severe  as  to  prevent  the  patient  moving  about. 
In  one  case  recently  under  my  charge,  the  subject,  a  gentleman  of 
about  forty  years  of  age,  was  often  seized  with  intense  vertigo  while 
walking  in  the  street,  and  wao  obliged  at  such  times  to  seize  hold  of  a 
lamp-post,  or,  if  this  was  not  within  reach,  to  sit  down  on  the  nearest 
door-step,  or  even  the  curbstone,  till  the  violence  of  the  attack  had  in 
a  measure  abated. 

Again,  the  least  movement  of  the  body,  the  slightest  attempt  at 
mental  exertion,  or  the  most  trifling  emotional  disturbance,  is  sufficient 
to  excite  it.     At  times  it  is  clearly  aggravated  by  indiscretions  in  diet 


CEREBRAL   CONGESTION.  37 

or  the  ingestion  of  even  a  small  quantity  of  any  stimulating  liquor,  and 
at  others  is  present  during  the  whole  period  of  being  awake.  There 
are  two  kinds  of  this  vertigo.  In  one  the  patient  seems  to  be  in  mo- 
tion ;  in  the  other  the  objects  about  him  appear  to  be  tumbling  topsy- 
turvy around  him.  In  the  latter  the  ground  in  front  appears  to  rise 
up  to  meet  him,  and  hence  he  walks  as  if  ascending  a  hill.  In  some 
cases  the  two  conditions  coexist  or  may  alternate.  Probably  no  symp- 
tom is  more  distressing  than  this.  It  almost  invariably  excites  more 
fear  of  serious  consequences  than  in  reality  should  attend  it,  and  it 
prevents  the  patient  taking  that  bodily  exercise  so  conducive  to  his 
restoration  to  health.  In  some  cases,  however,  it  is  entirely  absent, 
though  such  are,  I  think,  rarely  met  with,  and,  no  matter  how  intense 
it  may  be,  is  scarcely  ever  accompanied  by  nausea. 

In  other  cases  headache  constitutes  the  chief  physical  feature  of 
the  disease,  and  even  when  not  predominant  is  a  more  or  less  constant 
attendant  on  the  morbid  condition.  It  may  be  very  severe,  unfitting 
the  sufferer  for  the  slightest  mental  or  physical  exertion,  or  may  con- 
sist of  a  dull,  aching  pain,  very  wearing,  but  yet  bearable.  It  is  ag- 
gravated by  any  effort  to  use  the  mind  or  body,  and  especially  by  any 
cause — such  as  a  dependent  position  of  the  head,  the  use  of  stimulat- 
ing ingesta,  a  constriction  about  the  abdomen,  chest,  or  neck — likely 
to  increase  the  amount  of  the  intra-cranial  blood. 

In  some  cases  there  is  no  actual  pain,  except  as  the  immediate  con- 
sequence of  some  one  or  other  of  the  existing  causes  mentioned  ;  but 
tin-  patient  is  alw  :i ys  conscious  of  an  uncomfortable  sensation  in  the 
head,  which,  if  not  a  pain,  is  capable  of  being  readily  converted  into 
one.  This  is,  as  I  have  said,  sometimes  a  mere  feeling  of  fullness  or 
tightness,  or  as  if  the  brain — so  a  patient  described  it — were  "being 
gathered  together  into  a  heap,"  or,  as  another  said,  were  "being 
scratched  with  a  claw."  Again,  there  is  the  impression  thai  the  head 
idly  balanced  on  a  very  sharp  point,  and  that  some  effort  is 
required  to  keep  it  from  falling  off. 

Usually  the  painful  sensations  in  the  head  disappear  toward  night, 
or  on  the  attempt  to  sleep,  but  resume  their  violence  as  soon  as  the 
patient  awakes  in  the  morning. 

The    special    seizes    could    scarcely    be    expected    to    escape    giving 

evidences  of  derangement,  and  hence  among  the  chief  manifestations 

of   the    intra-cranial    disorder  are   those  connected  wit  h  the  perceptive 

organs. 

Thus  there  arc  noises  in  the  ears,  such  as  roaring,  rumbling,  or  Bing- 

ing,  and  occasionally  loud  reports,  such  as  might  be  produced  bj  the 
discharge  of  lire-arms.  A  gentleman,  recently  under  my  care  for  the 
affection  in  question,  informed  me  that  when  he  Brsl  experienced  the 
sensation  mentioned  he  was  Bitting  in  his  library,  quietly  reading, 
when  he  suddenly  heard  a  report  as  if  a  pistol  had  been  shot  off  within 


38  DISEASES   OF   TOE   BRAIN. 

a  foot  of  his  head.  He  jumped  to  his  feet,  expecting  to  see  an  assail- 
ant behind  him,  but,  to  his  surprise,  there  was  no  one  to  be  seen,  and  it 
was  very  evident  that  no  explosion  had  taken  place.  He  was  greatly 
astonished  at  this,  but  attributed  the  whole  matter  to  an  exaggeration, 
excited  by  his  irritable  nervous  system,  of  some  street  noise.  He  had 
no  further  experience  of  the  kind  till  the  following  morning,  when,  on 
rising  from  bed  after  a  wretched  night  of  sleeplessness,  he  again  heard 
the  sound,  and  this  time  it  was  as  nearly  as  possible  like  the  noise 
produced  by  striking  two  stoutly  bound  books  together  close  to  his 
ears.  After  this  there  was  scarcely  a  day  that  the  sound  was  not 
heard.  It  was  entirely  subjective,  as  persons  in  close  proximity  to  him 
at  the  time  heard  nothing. 

Several  such  cases  have  come  under  my  observation.  It  is  not  in 
all  that  the  sound  appears  to  be  in  the  ears.  In  some  it  has  seemed 
to  be  located  in  different  parts  of  the  head,  generally,  however,  in  the 
posterior  region. 

•  In  some  cases  patients  have  experienced  the  sensation  as  if  some- 
thing snapped  or  gave  way  within  the  head,  and  this  has,  in  a  few 
rare  instances,  been  attended  with  the  sudden  disappearance  of  some 
of  the  more  striking  symptoms.  Thus,  a  young  lady,  in  conseqtience 
of  an  intense  emotion,  was  seized  with  sudden  vertigo  and  pain  in  the 
head,  and  fell  to  the  floor  unconscious.  Recovering  her  senses  in 
a  few  minutes,  she  found  herself  unable  to  speak  a  word,  though  she 
uttered  in  an  excited  way  inarticulate  sounds  having  no  resemblance 
to  speech.  This  condition  continued  for  several  hours,  when  she  sud- 
denly felt  "  something  snap  "  in  the  head,  and  she  instantly  recovered 
the  power  of  talking.  The  vertigo,  pain  in  the  head,  and  other  symp- 
toms, persisted  for  two  or  three  months  afterward. 

In  another  case  the  onset  of  the  disease,  in  a  gentleman  who  had 
for  many  years  overworked  his  brain,  was  extremely  sudden,  and  was 
attended  with  facial  paralysis.  I  treated  him  for  this  latter  condition 
with  electricity,  with  but  little  benefit ;  but  one  day  he  struck  his 
head  violently  against  a  gas-burner  hanging  over  his  desk,  and  shortly 
afterward  felt  something  give  way  within  his  head  with  a  sharp,  snap- 
ping sound,  and  the  paralysis  instantly  disappeared,  after  having  lasted 
some  five  or  six  days. 

Such  cases  are,  in  the  present  state  of  our  knowledge,  inexplicable, 

The  ear  becomes  hypersesthetic,  and  loud  noises  are  therefore  dis- 
agreeable. At  times  the  sense  of  hearing  is  morbidly  acute,  while  at 
others  it  is  markedly  impaired.  Sounds  are  misinterpreted  with  some 
persons,  and  illusions  result.  This  is  especially  the  case  at  night,  when 
the  patient  is  lying  awake,  the  mind  stretched  to  its  utmost  tension. 
A  gentleman  informed  me  that  a  circumstance  with  which  most  per- 
sons are  familiar — the  conversion  of  the  sound  of  the  ticking  of  a  clock 
into  some  phrase  or  other — was  to  him  a  matter  of  agonizing  weari- 


CEREBRAL   CONGESTION.  39 

ness.  Night  after  night  as  he  lay  in  hed,  the  ticking  of  a  large  clock 
in  the  hall  seemed  to  be  the  constant  repetition  of  the  word  "  fare- 
well." Not  wishing  to  reveal  the  matter  to  others,  he  endured  for 
many  nights  the  consequent  suffering,  till  finally  he  made  an  excuse  for 
leaving  the  city.  But  still  the  wheels  of  the  railway  cars  seemed  to  be 
uttering  the  word  "  farewell,"  and  it  was  only  after  a  fatiguing  journey 
to  Baltimore  and  repose  in  a  quiet  room  that  he  escaped  the  infliction. 
In  addition  to  illusions,  hallucinations  of  hearing  are  not  uncom- 
mon, and  are  usually  in  the  form  of  whispered  words,  which  the 
patient  hears  with  as  much  vividness  as  though  they  were  real  utter- 
ances. Like  the  misinterpretations  of  real  sensorial  impressions,  these 
are  usually  experienced  at  night,  and  may  be  excited  by  any  circum- 
stance, mental  or  physical,  which  tends  to  increase  the  amount  of  blood 
circulating  in  the  intra-cranial  vessels.  Thus,  a  powerful  emotion,  an 
unusually  severe  mental  task,  a  strong  muscular  effort,  or  a  dependent 
position  of  the  head,  may  induce  them.  In  one  case,  that  of  a  gentle- 
man of  rather  obese  development,  a  whisper  of  some  kind  or  other 
was  always  heard  when  he  stooped  to  button  his  gaiter-boots.  In 
another,  straining  in  the  water-closet  frequently  caused  a  like  symp- 
tom. In  one  very  interesting  instance  the  sounds  were  like  those  of 
musical  instruments,  and  were  arranged  into  familiar  tunes,  to  the  no 
small  satisfaction  of  the  subject  ;  and  in  another  they  assumed  the 
similitude  of  the  bark  of  a  dog.  Occasionally  they  are  in  the  form 
of  commands  to  perpetrate  some  act  of  violence,  such  as  suicide.  A 
patient,  who  came  from  Brooklyn  to  consult  me,  heard  a  voice  whis- 
pering in  his  ear.  and  ordering  him  to  throw  himself  into  the  river. 
u  What  is  the  use  of  your  going  to  see  a  physician?"  it  said.  "The 
best  thing  you  can  do  is  to  kill  yourself.  You  are  of  no  service  to 
yourself  or  any  one  else.  Jump  overboard  and  end  the  matter  at 
once."  Though  these  hallucinations  never  imposed  upon  the  reason 
of  the  patient,  they  were  nevertheless  sufficiently  distressing,  giving 

rise,  as  they  did,  to  the  fear  that  he  might,  some  day  OI  other,  be  in- 
fluenced by  them  to  commit  an  act  which  he  abhorred. 

The  aural  speculum  is  almost,  if  not  quite,  as  valuable  as  the  oph- 
thalmoscope in  affording  important  information  relative  to  the  affec- 
tion under  notice  ;   and   I   have  been  in  the  habil   for  the  last    live  years 

of  employing  it  in  every  case  presenting  the  more  obvious  features  of 
the  disease.  I  do  nol  mean  to  be  understood  as  intimating  that  posi- 
tively affirmative  results  are  to  be  obtained  in  all  instances,  but  neither 
are  they  of  any  other  single  symptom.     That   the  tympanum  does 

afford    an    indication    of    the    state   of    the    intra-cranial    circulation    is 

sufficiently  evident,  from  a  consideration  of  the  experiments  performed 
by  my  friend  Prof.  U"«>-a  and  myself  relative  to  the  influence  of  the 

"•The  Influence  of  tin-  Disulphate  of  Quinine  over  the  [ntn-Cimnitl  CSreulatton." 
Psychological  and  Medico-Legal  Journ^  October,  1874,  p.  880. 


40  DISEASES   OF   THE   BRAIN. 

eulphate  of  quinine,  the  results  of  which  have  been  amply  confirmed 
by  the  subsequent  investigations  of  Prof.  Roosa,  as  well  as  by  those 
of  other  observers. 

In  the  cerebral  disorder  under  notice,  evident  congestion  will  almost 
always  be  observed  of  the  vessels  over  the  handle  of  the  malleus,  and 
the  tympanum  will  be  seen  to  be  of  a  light  pinkish  color.  In  some 
cases  we  are  prevented  making  the  usual  examination  owing  to  the 
accumulation  of  cerumen.  This  must  be  removed  by  forceps  or  by 
washing,  and  the  inspection  deferred  till  next  day. 

I  may  add  that  physicians,  wishing  to  observe  the  connection  be- 
tween cerebral  hyperemia  and  tympanic  congestion,  have  a  ready 
method  of  satisfying  themselves  on  this  point  by  examining  the  tym- 
panum before  and  after  the  subject  has  inhaled  a  few  drops  of  the 
nitrite  of  amyl.  This  was  first  done,  so  far  as  I  am  aware,  by  Mr. 
Galton,1  and  detailed  in  his  paper  entitled  "  Notes  on  the  Condition 
of  the  Tympanic  Membrane  in  the  Insane." 

The  faculty  of  vision  is  almost  invariably  more  or  less  disturbed. 
Sometimes  there  are  bright  flashes  of  light,  from  over-excitation  of  the 
retina,  and  these,  like  the  other  symptoms,  are  rendered  more  intense 
upon  mental  or  physical  exertion.  At  other  times  dark  spots — muscce 
volitantes — render  the  vision  indistinct ;  and  again  there  is  the  appear- 
ance of  an  undulatory  vapor,  such  as  is  seen  around  a  hot  stove,  or  on 
a  plain  heated  by  the  sun.  The  conjunctivae  are  suffused  ;  the  pupils 
contracted.  There  is  intolerance  of  light,  and  motion  of  the  eye- 
balls is  painful,  and  the  ophthalmic  symptoms  are  aggravated  by  the 
effort  to  use  the  eyes.  The  ocular  muscles  easily  become  fatigued, 
and  hence  pain  is  excited  by  any  attempt  to  read  or  to  adjust  the 
visual  foci  for  near  objects. 

Ophthalmoscopic  examination  shows  the  arteries  of  the  retina  to  be 
increased  in  size  and  tortuosity,  and  vessels  which  in  health  are  not  visi- 
ble are  now  clearly  perceived.  The  optic  disk  is  often  more  or  less 
congested,  exhibiting  the  appearance  to  which  Allbutt  has  applied  the 
name  "Congestion  Papilla,"  but  which  is  perhaps  more  generally 
known  as  "choked  disk."  The  tint  of  the  choroid  is  deeper  than  it  is 
when  in  a  normal  condition. 

The  effect  of  cerebral  congestion  in  giving  rise  to  visual  hallucina- 
tions has  long  been  known,  though  it  often  happens  that  in  practice 
the  value  of  the  fact  as  an  indication  of  the  state  of  the  intra-cranial  cir- 
culation is  in  a  great  measure  disregarded.  In  another  work3  I  have 
considered  the  subject  of  hallucinations  of  sight  at  some  length,  and,  as 
showing  the  influence  of  undoubted  cerebral  congestion  in  producing 
them,  I  quote  the  following  case  which  occurred  in  my  own  experience  : 

1  "West  Riding  Lunatic  Asylum  Medical  Reports,"  vol.  iii.,  1873,  p.  258. 
'"Spiritualism  and  Allied  Causes  and  Conditions  of  Nervous  Derangement."     New 
York,  1876,  p.  8. 


CEREBRAL   CONGESTION.  41 

"A  gentleman  under  the  professional  charge  of  the  writer  can 
always  cause  the  appearance  of  images  by  tying  a  handkerchief  moder- 
ately tight  around  his  neck,  and  there  is  one  form  which  is  always 
the  first  to  come  and  the  last  to  disappear.  It  consists  of  a  male  figure 
clothed  in  the  costume  worn  in  England  three  hundred  years  ago,  and 
hearing  a  striking  resemblance  to  the  portraits  of  Sir  Walter  Raleigh. 
This  figure  not  only  imposes  on  the  sight,  but  also  on  the  hearing  ;  for 
questions  put  to  it  are  answered  promptly." 

"  A  similar  instance  is  related  in  '  Nicholson's  Journal.' l  '  I  know  a 
gentleman,'  he  states,  '  in  the  vigor  of  life,  wrho,  in  my  opinion,  is  not 
exceeded  by  any  one  in  acquired  knowledge  and  originality  of  deep 
research,  and  who  for  nine  months  in  succession  was  always  visited 
by  a  figure  of  the  same  man,  threatening  to  destroy  him,  at  the  time 
of  his  going  to  rest.  It  appeared  upon  his  lying  down,  and  instantly 
disappeared  when  he  resumed  the  erect  position.'  " 

A  case  somewhat  like  the  first  of  the  two  foregoing  is  referred  to 
by  De  Boismont,3  in  which  an  individual  was  able  to  obtain  hallucina- 
tions of  sight  by  inclining  his  head  a  little  forward.  By  this  move- 
ment, the  return  of  blood  from  the  interior  of  the  cranium  was  pre- 
vented, and  hence  a  state  of  repletion  favorable  to  the  production  of 
hallucinations  was  induced. 

Now,  in  the  state  of  cerebral  hyperemia  which  results  from  exces- 
sive brain-work  or  intense  emotional  disturbance,  a  condition  exists 
not  essentially  different  from  that  present  in  the  case  referred  to,  ex- 
cept in  the  circumstance  that  the  excess  of  blood  is  mainly  arterial, 
instead  of  venous,  and  that  hence  the  congestion  is  more  active  than 
passive.  But  it  must  be  borne  in  mind  that  it  requires  a  very  great 
degree  of  hyperemia  to  cause  the  production  of  visual  hallucinations, 
and  therefore  thai  we  are  not  to  expect  them  to  occur  in  all  patients 
wrho  are  its  subjects.  So  far  as  my  own  experience  extends,  only  about 
one  in  five  exhibits  the  symptom  with  any  degree  of  distinctness. 

Double  vision  is  occasionally  a  phenomenon  of  the  disease  in  ques- 
tion, though  it  is  generally  transient,  and,  as  rlrishaber  remarks,  ordi- 
narily <<nly  manifested  in  regard  to  bright  objects. 

This  author  also  ipeaks  <d  b  peculiarity  of  sight  which  has  not 
Come   under  my  notice.      "  A  patient,"  he   Bays,  "looks   at    himself  in  a 

with  astonishment,  as  if  he  had  forgotten  his  appearance.  An- 
other is  horrified  at  his  image,  which  represents  a  being  altogether  of 
different  traits  from  those  which  he  conceive. I  himself  to  possess.    But 

he  IB  not   alarmed,  for  lie  knuus  that    it    is  only  hi-  perception   which  is 

changed.     This  aberration  exists  not  only  as  regards  his  own  person, 
!>ut  other  objects  as  well.    The  patient  finds  men  and  things  changed  ; 

1    VoL   \i.,   p.    166. 

'"History  «if  Dreams,  Visions,  Apparitions,  etc."  American  edition.  Philadelphia, 
1885. 


42  DISEASES   OF   THE   BRAIN. 

he  is  astonished,  always  astonished,  and  it  seems  to  him  that  he  is  a 
being  transported  to  another  planet."  ' 

The  sense  of  smell  is  very  often  lost,  perverted,  or  intensely  exalted. 
Perhaps  the  second  named  of  these  changes  is  the  one  most  frequently 
met  with.  I  have  a  patient  now  under  my  care,  a  gentleman,  who 
from  over-mental  work  is  suffering  from  cerebral  hyperemia,  and  who 
constantly,  while  awake,  smells  the  odor  of  illuminating  gas.  So  strong 
is  this,  that  he  is  at  times  unable  to  resist  the  impression  that  gas  is 
escaping  somewhere,  and  he  goes  from  burner  to  burner  of  his  resi- 
dence and  office  seeking  for  the  imaginary  leak.  Another  is  constantly 
sensible  of  the  smell  of  turpentine  or  new  paint,  and  another  has  the 
odor  of  mint  constantly  present  in  his  nostrils. 

The  taste  is  also  occasionally  affected  in  like  manner,  usually,  so 
far  as  my  experience  goes,  in  the  way  of  perversion.  "  Things  don't 
taste  as  they  used  to,"  is  a  common  complaint,  and  the  saliva  and  buc- 
cal mucus  often  give  the  gustatory  impression  of  other  substances.  It 
is  not  at  all  unlikely,  however,  that  "  the  bad  taste  in  the  mouth,"  so 
often  mentioned  by  patients,  is  due  to  a  real  change  in  the  properties 
of  the  saliva  or  mucus.  I  have  observed  several  cases  in  which  any 
mental  or  emotional  strain  was  sufficient  to  cause  a  bitter  or  other  un- 
pleasant taste  in  the  mouth,  and  the  same  phenomenon  is  quite  common 
a<*  a  consequence  of  gastric  disturbance.  Krishaber  cites  two  cases  in 
which  both  smell  and  taste  were  entirely  abolished. 

Sensation  and  the  power  of  motion  are  usually  affected,  and  general- 
ly, though  not  always,  on  one  side  of  the  body  only.  Thus,  the  arm  or 
the  leg  feels  heavy,  and  a  feeling  as  of  ants  crawling  over  it,  pins  and 
needles  sticking  in  it,  or  as  if  the  limb  were  "asleep,"  is  experienced. 
Sometimes  these  sensations  are  confined  to  the  face,  the  muscles  of 
which  feel  drawn  or  tight,  and  the  skin  of  which  has  the  various  indica- 
tions of  anaesthesia  mentioned.  Most  frequently,  however,  they  are,  I 
think,  experienced  on  the  scalp,  giving  rise  to  the  several  sensations 
already  mentioned. 

Again,  there  is  an  exaltation  of  the  sensibility  of  the  skin  and  of 
the  sensory  nerves  generally,  and  thus  neuralgic  pains  are  felt  in  vari- 
ous parts  of  the  body  ;  or  the  cutaneous  surface  is  extremely  sensitive 
to  the  impression  made  upon  it,  whether  of  heat,  cold,  or  slight  pres- 
sure. 

Slight  convulsive  actions  or  twitchings  of  individual  muscles  or 
groups  of  muscles  are  generally  present.  Sometimes  a  few  fibers 
only  are  affected.  The  face,  and  especially  the  eye-lids  and  angles  of 
the  mouth,  is  particularly  liable  to  be  thus  involved.  The  muscular 
strength  is  usually  weakened.  The  patient  tires  after  slight  physical 
exertion,  and  occasionally  certain  muscles,  such  as  the  deltoid  and 
tibialis  anticus,  become  distinctly  paretic,  so  that  there  is  an  impaii 

1  Op.  cit.,  p.  168. 


CEREBRAL   CONGESTION.  43 

ment  of  the  ability  to  raise  the  arm  from  the  side  or  to  elevate  the 
foot  sufficiently  high  in  walking  to  clear  ordinary  inequalities  in  the 
pavement.  The  dynamometer  shows  the  grasp  of  the  hand  of  one  or 
other  side,  or  of  both,  to  be  weakened,  and  the  line  made  by  the  dy- 
namograph  is  zigzag  or  uniformly  depressed. 

The  appetite  is  capricious,  and  the  stomach  acts  imperfectly  and 
sluggishly.  The  gastric  juice  is  not  secreted  in  sufficient  quantity  for 
the  purposes  of  digestion,  and,  the  peristaltic  action  of  the  stomach 
being  weakened,  the  food  remains  within  it  a  long  time  undigested 
and  undergoing  fermentation.  Regurgitations,  both  of  the  solid  con- 
tents and  of  gases,  are  common,  and  the  patient  tastes  his  meals  sev- 
eral hours  after  they  have  been  swallowed.  Gases  accumulate  in  the 
stomach,  and  give  rise  to  the  sense  of  fullness  experienced  even  after  a 
very  slight  repast  has  been  taken.  Such  symptoms  are  usually  classed 
under  the  name  of  "  nervous  dyspepsia,"  a  not  improper  designation, 
if  it  does  not  lead  us  into  the  error  of  regarding  them  as  of  primary 
importance,  instead  of  considering  thern,  as  they  are,  merely  consequent 
on  the  head  trouble. 

The  bowels  are  ordinarily  costive,  though  at  times  this  condition 
alternates  with  diarrhoea. 

The  urine  is  in  some  patients  scanty  and  high-colored,  in  others  it 
is  profuse  and  almost  as  pale  as  water.  Oxalate  of  lime  is  often  pres- 
ent, and  an  excess  of  phosphates  an  invariable  condition,  so  far  as 
my  experience  extends.  I  have  already  spoken  of  this  circumstance. 
Whether  or  not  the  phosphates  in  the  urine  are  to  be  regarded  as  the 
ashes  of  the  nervous  system,  and  hence  a  measure  of  the  amount  of 
nerve  tissue  decomposed,  there  is  no  doubt  that  they  are  inordinately 
increased  after  intense  mental  or  emotional  strain. 

I  have  spoken  of  the  heat  of  the  head  of  which  the  patient  gener- 
ally complains.  Thai  there  is  a  real  increase  of  temperature  can  often 
he  perceived  by  the  hand  or  by  the  use  of  an  ordinary  thermometer. 
lint  in  some  cases  the  actual  rise  of  temperature  is  so  Blight,  notwith- 
standing the  feeling  of  heat,  which  the  patient  experiences,  that  we  can- 
not deteel   it  1)V  either- of  these   means.      In  such  cases  resort  Bhould  be 

had  to  the  thermo-elect rir  differential  calorimeter  of  Lombard,  by 
which  very  minute  changes  of  temperature  can  be  detected,  and  the 

part  of  the  brain  in  which  the  temperature  is  highest  be  readily  ascer- 
tained. The  experiments  of  Lombard,  performed  several  years  ago, 
show  very  beautifully  the  influence  of  cerebral  action  in  augmenting 
the  external  heat  of  the  head,  and  it  maybe  remembered  that,  over 
two  years  ago,  [detailed  to  the  Neurological  Society  the  results  of 
some  experiments  of  my  own  in  the  same  direction.  Forseveral  years 
past  1  have  never  examined  a  pat 'nut  presenting  the  more  obvious 
features  of  cerebral  hyperemia  without  carefully  determining  the  BUr- 
face  temperature  Of  various  parts  of   the  scalp.      At  times  and  in  Borne 


44  DISEASES   OF   THE   BRAIN. 

regions  the  elevation  reaches  two  degrees  of  centigrade  above  the 
normal  standard.1 

But  one  of  the  chief  categories  of  symptoms  remains  to  be  consid- 
ered— chief,  at  least,  so  far  as  the  more  obvious  appearances  go,  though, 
like  the  other  visceral  derangements,  I  must  regard  these  as  being  due 
to  the  brain  disorder — and  that  is  the  group  of  phenomena  connected 
with  the  heart.  To  Krishaber,  in  the  work  already  cited,  belongs  the 
credit  of  being  the  first  to  call  attention  to  this  remarkable  series,  for 
in  the  publication  of  my  own,  to  which  I  have  referred,  it  was  in  a  great 
measure  overlooked.  As  Krishaber  remarks,  the  troubles  of  the  circu- 
lation consist  especially  in  an  irritability  of  the  vascular  system,  so  that 
the  least  movement,  such  as  rising  erect  from  the  sitting  posture,  or  to 
the  sitting  from  the  recumbent,  leads  to  an  acceleration  of  the  pulse 
of  from  20  to  30  or  even  40  beats  a  minute.  Besides  this,  there  are 
frequent  and  violent  palpitations,  either  spontaneous,  or  provoked  by 
the  most  insignificant  causes,  either  mental  or  physical. 

Emotional  excitement  is,  however,  the  most  prolific  cause  of  cardiac 
disturbance  in  patients  affected  with  cerebral  hyperemia,  and  at  times 
leads  to  serious  results.  The  pulsations  of  the  heart  may  be  so  irregu- 
lar and  the  action  of  the  organ  so  strong  as  to  induce  grave  inter- 
ference with  the  respiratory  apparatus.  Upon  one  occasion  a  lady, 
while  in  my  consulting-room,  was  seized  with  a  paroxysm  of  the  kind 
in  question,  of  so  severe  a  character  that  for  a  moment  or  two  I  thought 
she  was  about  to  die.  For  several  months  she  had  been  wakeful,  had 
suffered  from  vertigo  and  slight  pain  in  the  head,  and,  while  relating  to 
me  her  symptoms,  a  blast  near  by,  where  a  cellar  was  being  excavated, 
exploded,  and  produced  so  violent  and  sudden  a  shock  as  to  bring  on 
the  excessive  cardiac  action  mentioned.  The  heart  throbbed  with  so 
great  a  degree  of  violence  that  its  pulsations  could  be  readily  seen 
through  her  dress  and  heard  at  the  distance  of  two  or  three  feet ;  her 
face  and  neck  became  livid,  and,  gasping  for  breath,  she  fell  to  the  floor 
insensible.  In  a  very  short  time,  however,  the  inordinate  movements 
ceased,  and  she  recovered  consciousness. 

Physical  examination  of  the  heart  fails  in  these  cases  to  reveal 
the  existence  of  any  organic  lesion. 

In  the  intervals  between  the  paroxysms  of  inordinate  cardiac  ac- 

1  Since  the  above  was  written  I  have  become  acquainted  with  some  recent  experiments 
of  Prof.  Broca,  of  Paris,  in  the  same  direction.  As  he  does  not  refer  to  either  Lom- 
bard's or  my  own  experiments,  though  the  former  ("  Experiments  on  the  Relation  of  Heat 
ta  Mental  Work")  were  published  in  the  New  York  Medical  Journal,  January,  18G7,  p. 
19S,  and  a  synopsis  of  my  own  in  the  Journal  of  Nervous  and  Mental  Disease,  January, 
1876,  I  presume  he  is  unacquainted  with  cither.  Prof.  Broca  ascertained  by  means  of 
thermometers,  applied  to  different  parts  of  the  scalp,  that  the  external  temperature  was 
affected  by  different  internal  morbid  and  physiological  conditions,  and  hence  confirmed 
the  pre.  ions  observations  of  Lombard  ami  myself.  His  experiments  would  have  yielded 
much  more  delicate  and  accurate  results  if  he  had  employed  Lombard's  instrument. 


CEREBRAL   CONGESTION.  45 

tion,  the  pulse  is  small,  often  slow,  soft,  compressible,  but  by  no 
means  regular,  either  in  force  or  frequency.  Intermissions  of  the 
beats  are  a  common  phenomenon,  and  give  rise  to  anxiety  and  morbid 
apprehensions  in  the  patient. 

Krishaber  states  that  at  the  very  beginning  of  the  disorder  there 
is  sometimes  present  a  series  of  phenomena  simulating  fever,  such 
as  a  chill,  followed  by  a  distinct  period  of  febrile  excitement.  Dur- 
ing this  last  stage  the  temperature  of  the  body  is  elevated  almost 
half  a  degree  centigrade,  or  nearly  a  whole  degree  of  our  scale,  and 
may  even  be  double  this.  This  accession  may  be  repeated  with  some 
degree  of  periodicity,  but  it  soon  ceases,  and  does  not  reappear  after 
the  full  development  of  the  disease. 

I  have  observed  this  condition  in  about  one  third  of  the  cases 
that  have  come  under  my  observation,  though  usually  close  question- 
ing is  necessary  to  elucidate  the  fact  of  its  existence,  so  little  im- 
pression does  it  make  upon  the  mind  of  the  patient.  Sometimes, 
however,  the  paroxysms  are  of  such  severity  as  to  excite  the  belief 
that  they  are  of  malarious  origin,  and,  being  treated  with  quinine, 
they  and  the  other  symptoms  attendant  on  the  disease  are  greatly 
aggravated. 

During  the  most  intense  period  of  the  disease  there  are  occasion- 
ally paroxysms  characterized  by  entire  inability  to  move  a  muscle  of 
the  body,  the  consciousness,  respiration,  and  circulation  not  being  ma- 
terially disturbed.  I  have  never  had  a  case  which  exhibited  these 
symptoms,  though  Krishaber  appears  to  regard  them  as  not  uncommon. 
On  the  other  hand,  syncope  with  complete  loss  of  consciousness,  which 
he  speaks  of  as  rare,  is,  according  to  my  experience,  by  no  means 
uncommon.  With  both  of  these  conditions,  there  is  an  almost  con- 
tinuous precordial  pain,  sometimes  severe  enough  to  excite  the  idea 
of  the  existence  of  angina  pectoris,  and  causing  the  gravest  appre- 
hensions on  the  part  of  the  patient  and  his  friends. 

That  one  of  the  primary  effects  of  intellectual  exertion  <>r  emo- 
tional disturbance  is  an  increase  in  the  amounl  of  blood  circulating 

through  the    brain,  does  not  admit   of   a  doubt,  except   from  those  who, 

still  refusing  to  learn,  contend  that  the  cerebral  circulation  i-  not  snb- 
jecl  to  variation  under  any  circumstances.  Experimental  physiology 
haa,  however,  determined  this  point  so  positively  in  the  affirmative 
that  it  i>  scarcely  necessary  to  adduce  the  evidence  in  its  Bttpport.  It 
will  be  sufficient  to  recall  the  numerous  facts  observed  by  others  and 
myself  with  reference  to  the  immediate  cause  of  sleep,  by  which  it  is 
shown  that  during  the  condition  of  wakefulness  'he  quantity  of  blood 
in  the  brain  is  much  <_rreater  than  it   is  during  sleep,  the  first  being  a 

state  of    intellectual    activity,  the    latter   one   of   almost    iph lt€  I 

bra!  resti 

re  mental  exercise  inordinate!]  augments  the  activity  of 


46  DISEASES   OF   THE   BRAIN. 

the  cerebral  circulation.  The  blood-vessels  become  over-distended, 
and,  if  the  brain  be  kept  long  in  a  condition  of  extraordinary  action, 
they  may  be  rendered  incapable  of  returning  spontaneously  to  their 
normal  dimensions.  Like  a  bladder  filled  to  repletion  with  urine, 
they  become  in  a  manner  paralyzed  and  unable  to  contract  upon  their 
contents.  They  lose,  to  a  certain  extent,  their  elasticity,  and,  like  the 
India-rubber  band  kept  too  long  around  a  large  bundle  of  papers,  they 
do  not  regain  their  natural  size  even  when  the  distention  is  removed. 
A  state  of  cerebral  hyperemia  is  thus  induced,  which  gives  rise  to  a 
set  of  perfectly  characteristic  symptoms,  and  which  is  fraught  with 
peril  to  those  in  whom  it  occurs. 

In  a  monograph  published  some  seven  years  ago,  Dr.  M.  Krishaber1 
described  a  disorder  of  the  brain  and  heart  which  is  probably  identi- 
cal with  the  one  under  consideration,  and  to  which,  under  the  name 
of  cerebral  hyperemia,  or  the  prodromatic  stage  of  cerebral  hypere- 
mia, I  called  attention  in  the  first  edition  of  my  ';  Treatise  on  Diseases 
of  the  Nervous  System,"  published  in  1871.  Krishaber's  studies  have 
very  considerably  advanced  our  knowledge  of  the  subject,  and,  as  my 
own  more  recent  investigations  and  enlarged  experience  have  tended 
still  further  to  the  elucidation  of  a  very  interesting  and  important 
condition  of  the  nervous  system,  I  have  thought  it  would  not  be  out 
of  place  to  bring  some  of  the  more  notable  results  of  our  labors  to  the 
notice  of  the  Neurological  Society.  It  may  be  as  well,  however,  to 
state  here,  at  the  outset,  that  I  differ  with  Krishaber  entirely  relative 
to  the  pathology  of  the  disorder  we  have  both  described,  and  that  I 
am  of  the  opinion  that  the  cardiac  symptoms  upon  which  he  lays 
great  stress  are  really  of  quite  secondary  importance.  In  other  re- 
spects there  is  no  essential  point  of  difference  between  us  in  the  repre- 
sentations of  an  affection  studied  independently  of  each  other,  and 
from  altogether  different  standpoints. 

The  disease  is  sometimes  developed  with  great  suddenness,  but 
ordinarily  it  advances  little  by  little  to  completeness.  When  the 
former  is  the  case,  the  patient  experiences,  under  the  influence  of 
great  mental  excitement,  pain  in  the  head,  vertigo,  an  inability  to 
speak,  or,  at  least,  imperfection  of  articulation.  There  are  noises  in 
the  ears,  flashes  of  light  before  the  eyes,  and  occasionally  for  a  short 
time  double  vision.  The  heart  beats  with  increased  force  and  rapid- 
ity, and  is  more  or  less  irregular  in  its  action  ;  the  face  is  flushed,  and 
a  feeling  of  suffocation  is  experienced.  If  he  attempts  to  walk,  his 
gait  is  uncertain  or  staggering,  not  only  in  consequence  of  the  vertigo 
present,  but  from  actual  loss  of  power  in  the  limbs.  Numbness  is 
commonly  felt  in  some  part  of  the  body,  and  clonic  spasms  of  the 
muscles,  notably  of  those  of  the  face,  are  generally  present. 

With  all  these  physical  symptoms,  there  are  others  indicating  men- 
1  "De  la  nevropathic  ccr^bro-cardiaque."     Paris,  18*73. 


CEREBRAL   CONGESTION.  47 

tal  disturbance.  Chief  among  these  are  hallucinations,  or  illusions  of 
the  senses,  particularly  of  sight  and  hearing.  Insomnia  is  an  almost 
invariable  attendant,  and  what  little  sleep  the  patient  olsrtains  is  inter- 
rupted by  unpleasant  or  even  frightful  dreams.  Gradually  the  disor- 
der becomes  established,  and  then  other  functions,  especially  those 
connected  with  digestion,  are  deranged.  From  the  first  the  urine  is 
loaded  with  urates  and  phosphates. 

As  instances  of  the  suddenness  with  which  the  disease  may  make 
its.onset,  I  cite  the  following  cases  from  my  note-book  : 

F.  H.,  a  gentleman  engaged  in  a  manufacturing  business  which  re- 
quired all  his  attention  to  make  it  profitable,  was  informed  one  morn- 
ing by  his  superintendent  that  a  large  lot  of  material  had  been  spoiled. 
He  at  once  experienced  an  intense  sensation  of  vertigo,  a  sharp  pain  in 
the  head,  palpitation  of  the  heart,  and  would  have  fallen,  had  he  not 
been  supported  by  the  bystanders.  There  were  also  a  roaring  sound 
in  the  ears  and  flashes  of  light  before  the  eyes.  On  attempting  to 
stand,  the  vertigo  and  palpitations  were  increased.  There  was  at  no 
time  loss  of  consciousness,  though  the  ideas  were  confused  and  the 
speech  thick.  In  the  course  of  a  few  hours  the  severity  of  these 
symptoms  diminished,  but  that  night  he  was  unable  to  Bleep,  and  in 
tlic  morning  the  morbid  phenomena  reappeared,  though  with  dimin- 
ished violence.  For  several  months  afterward  he  was  troubled  with 
wakefulness,  a  sense  of  fullness  and  tightness  in  the  head,  occasional 
weakness  of  the  limbs,  slight  numbness,  and  a  total  inability  to  exert 
his  mind  in  his  business  affairs  without  an  increase  in  all  the  symp- 
toms,    ruder  appropriate  treatment  he  entirely  recovered. 

S.  L.,  a  book-keeper,  after  a  day  of  unusually  arduous  work,  left 
his  place  of  business  to  go  home.  He  had  hardly  taken  half  a  dozen 
steps  when  he  was  seized  with  vertigo,  and  fell  unconscious  on  the  side- 
walk. He  almost  immediately  regained  his  senses,  hut.  on  trying  to 
stand,  found  that  he  was  paralyzed  in  both  legs,  and  that  the  Least 
motion  of  the  body  broughl  on  a  return  of  the  vertigo,  which  was  now 
attended  with  pain  in   the  head,  mostly  in  the  frontal  region,  noises 

in   the    ears    and    indist  inctness   of    vision.       On    attempting   to    speak, 

his  articulation  was  so  imperfecl  thai  he  could  scarcely  be  understood. 

There    was   an    uneasy    feeling   at    the    pit    of   the  stomach,  but   neither 

nausea  nor  palpitation  of  the  heart,  though  the  action  of  this  organ 
was  irregular,     tie  was  taken  home  in  a  carriage,  and  after  a  sleepless 

night  found  himself  very  little  better,  except  in  the  fact  that,  though 
his  legs  were  -till  weak,  there  was  no  absolute  paralysis.     Gradually  he 

gol  somewhat   better,  though  walking  always  produced  vertigo,  and 

his  gait    was  similar  to    that    of   a    partially    drunken    man.  :^  he    found 

it  impossible  to  avoid  a  zigzag  course,  or  a  decided  tendency  to  sidle 

OTer  tO  the  edge  of  the  pavement.  Sleep  was  almost  every  night  im- 
perfect, being  disturbed  by  dreams  of  difficulties  from  which  he  could 


48  DISEASES   OF   THE   BRAIN. 

not  extricate  himself,  such  as  the  house  being  on  fire,  and,  on  his  spring- 
ing from  bed,  discovering  his  door  to  be  locked  on  the  outside  ;  falling 
into  the  wate^  and  being  on  the  point  of  drowning  from  inability  to 
divest  himself  of  heavy  boots,  and  so  on.-  Mental  application  was  im- 
possible without  leading  to  an  aggravation  of  all  his  symptoms,  and 
the  least  emotional  excitement  was  sufficient  to  augment  them  to  a 
high  degree.  He  suffered  in  this  manner  for  nearly  a  year,  before  re- 
lief was  obtained,  being  in  that  time  treated  with  remedies  directed  to 
the  removal  of  cerebral  anaemia,  when,  in  fact,  the  intra-cranial  condi- 
tion was  directly  the  opposite. 

M.  S.,  a  young  lady,  aged  nineteen,  and  without  notable  predisposi- 
tion to  neurotic  disturbances,  was  deeply  chagrined  at  not  being  in- 
vited to  a  ball  at  which  she  had  confidently  anticipated  being  present. 
While  talking  the  matter  over  with  some  friends,  she  suddenly  expe- 
rienced a  severe  pain  in  the  head,  vertigo,  noises  in  the  ears,  flashes  of 
light  alternating  with  darkness,  and  violent  palpitation  of  the  heart. 
At  the  same  time  a  peculiar  thrilling  sensation  was  felt  throughout  the 
body,  especially  on  the  left  side.  These  symptoms  continued  with 
great  intensity  all  that  day,  notwithstanding  that  stimulants  and  anti- 
spasmodics were  administered  in  large  quantities  by  the  physicians 
called  to  attend  her.  During  the  night,  every  attempt  to  turn  over  in 
bed  was  attended  with  vertigo  and  palpitation  of  the  heart.  For  over 
a  year  there  was  very  little  improvement,  and  the  course  of  the  disease 
was  not  essentially  different  from  the  other  cases  cited.  The  most  dis- 
tressing symptom  in  her  case  was  the  persistence  of  the  insomnia,  it 
rarely  happening  that  she  obtained  over  an  hour  or  two  of  unref resil- 
ing slumber.  When  she  came  under  my  care,  some  thirteen  months 
after  the  inception  of  the  disease,  I  found  that  the  affection,  though 
mitigated  in  the  violence  of  the  attendant  phenomena,  was  still  suffi- 
ciently distressing  to  impair  her  capacity  for  enjoyment  and  her  useful- 
ness to  others.  Recognizing  the  existence  of  congestion  of  the  brain 
rather  than  anremia,  for  which  she  had  uniformly  been  treated,  I  acted 
accordingly,  and  had  the  satisfaction  of  seeing  her  gradually  improve, 
till,  at  the  end  of  less  than  six  weeks,  she  was  as  well  as  she  ever  had 
been  in  her  life. 

The^e  ca^es  nre  cited,  not  as  exhibiting  perfect  representations  of 
cerebral  hypera?mia,  but  merely  for  the  purpose  of  illustrating  the 
suddenness  with  which  the  condition  may  be  induced.  They  are  se- 
lected at  random  from  many  others  occurring  in  my  hospital  and  pri- 
vate practice,  and  detailed  in  my  note-book. 

Eventually,  no  matter  how  brusque  maybe  the  development  of  the 
symptoms,  the  course  of  the  disease  is  not  materially  different  from 
that  of  the  more  gradually  established  form  next  to  be  described.  In- 
deed, there  are  no  differences  except  as  regards  the  order  of  sequence 
in  which  the  symptoms  ensue  and  in  the  fact  that,  in  the  present  form, 


CEREBRAL   CONGESTION.  49 

there  is,  in  the  beginning,  a  greater  degree  of  intensity  in  the  abnormal 
manifestations. 

In  the  majority  of  cases,  therefore,  the  affection  is»evolved  more 
slowly,  and  the  order  of  appearances  of  the  phenomena  somewhat  dif- 
ferent. 

The  foregoing  constitute  the  ordinary  assemblage  of  symptoms 
which  are  first  met  with  in  congestion  of  the  brain.  Some  ©f  them 
may  be  absent,  others  so  slightly  manifested  as  to  escape  ordinary  ob- 
servation, and  others,  again,  so  strongly  exhibited  as  to  excite  the  grave 
apprehensions  of  the  patient  and  his  friends,  and  to  require  him  to  keep 
his  bed.  Generally,  however,  they  are  not  so  severe  as  to  prevent  him 
attending  in  a  measure  to  his  ordinary  avocations,  and  they  may  alto- 
gether disappear,  either  spontaneously  or  in  consequence  of  appropriate 
medical  treatment. 

A  spontaneous  cure  is,  however,  rare,  and,  without  proper  manage- 
ment on  the  part  of  the  patient  or  his  medical  attendant,  the  symptoms 
pass,  sooner  or  later,  into  one  of  the  fully  developed  forms  mentioned. 
Thus,  of  the  cases  that  have  been  under  my  observation,  the  disease 
was  arrested  at  the  first  stage  in  about  ninety-five  per  cent,  by  appro- 
priate treatment,  while  there  was  not  a  single  instance  of  spontaneous 
cure. 

The  fact  that  abscesses  of  the  liver  may  be  associated  with  cere- 
bral hyperemia,  probably  as  a  direct  result,  was  pointed  out  by  me1  a 
short  time  since,  and  several  cases  detailed  in  which  aspiration  had  led 
to  the  evacuation  of  pus  from  the  liver.  Since  the  publication  of  the 
original  paper  on  the  subject,  other  similar  cases  have  come  under  my 
notice,  and  like  ones  have  been  reported  by  other  observers.1  It  is 
probable,  however,  that  other  brain  lesions — as  is  well  known  of  blows 
upon  the  head — arc  capable  of  inducing  the  condition  in  question. 
The  subject  will  be  more  appropriately  considered  in  detail  in  my 
forthcoming  work  on  mental  disorders. 

Second  Stage.  ".  The  Apoplectic  Fbrm. — Occasionally  this  va- 
riety of  cerebral  congestion  is  initial,  but  ordinarily  it  is  preceded  by 
the  group  of  symptoms  just  detailed.  In  either  event  theonsel  is  gen- 
erally sudden.  The  patient  is  perhaps  walking  in  the  street,  when  lie 
rers,  loves;  consciousness,  and  falls.  The  loss  of  intelligence  and 
sensibility  is,  however,  rarely  complete,  and  may  last  but  a  few  minutes 
■  ■I-  even  leconds,  though  sometimes  continuing  for  several  hours. 

Paralysis,  to  a  greater  or  less  extent,  is  always  present   tor  a  time. 

'"On  Obscure  Abscesses  of  tbe  Liver;    their  Association  with  Hypochondria  and 
their  Treatment."     8t.  /.■mix  Clinical  Record,  June,  181 

"•  The  Diagnosis  oi   U>sc«      of  the  Lircr  by  Symptoms  of  Cerebral  Hypcrsemia,"  etc. 
li\  .1.  Marion  Sims,  U.  D.     Virginia  Medical  Monthly,  January,  L880. 

"  Hypeneinia  <<f  tli"  Brain  associated  with  Hepatic  Abscess,"  by  w.  II.  !><•  Witt,  M.  D 
Medical  GauetU,  April  3,  1880. 
5 


50  DISEASES   OF   THE   BRAIN. 

One  limb  only  may  be  affected,  or  tbose  of  one  side,  or  all  four  mem- 
bers. It  is  never  complete,  the  patient  being  able  to  perform  some 
movements,  th*ough  not  to  exert  his  full  strength.  The  face  is  rarely 
involved,  and  the  patient,  though  answering  briefly  when  addressed  in 
a  loud  voice,  speaks  indistinctly  and  with  difficulty.  The  respiration 
is  loud,  slow,  but  rarely  stertorous,  and  it  is  not  often  that  there  is  * 
puffing  of  the  lips  and  cheeks.  The  pulse  is  slow,  hard,  and  full. 
Sometimes  the  face  is  flushed,  and  sometimes  it  is  unusually  pale. 
The  sphincters  generally  retain  their  power.  The  senses,  though 
weakened,  are  often  capable  of  being  exercised  by  tolerably  strong 
excitations.  A  bright  light  causes  uneasiness  and  closure  of  the  eye- 
lids. A  loud  noise  is  productive  of  discomfort,  and  a  limb,  when 
pinched,  is  withdrawn.  The  power  of  the  mind  is  greatly  lessened, 
and  some  faculties  are  altogether  abolished.  Answers,  more  or  less 
direct,  are  given  to  simple  questions  put  in  a  loud  tone,  but  even 
moderate  intellectual  action  seems  to  be  impossible. 

Gradually  the  attack  passes  off,  leaving  the  patient  in  a  state  of 
mental  and  physical  depression,  which  may  last  for  several  days.  The 
paralysis  usually  disappears,  but  occasionally  it  does  not,  one  or  more 
limbs  or  muscles  remaining  permanently,  or  for  a  long  time,  disabled. 

It  sometimes  happens,  however,  that  the  termination  is  not  so  favor- 
able. The  vessels  may  remain  congested,  serum  may  be  effused,  and 
death  may  result  without  there  being  any  vascular  lesion.  Two  cases 
have  come  under  my  notice,  in  which  death  ensued  from  this  cause  in 
first  attacks. 

A  person  who  has  once  had  a  paroxysm,  such  as  has  been  described, 
is  thereby  rendered  more  liable  to  subsequent  seizures,  each  one  of 
which  still  further  permanently  impairs  his  mental  and  physical  powers. 
In  one  case,  occurring  in  my  practice,  there  have  been  eleven  attacks 
in  five  years  ;  and  in  another,  fourteen  in  four  years.  In  both  of  these, 
and  in  several  similar  instances  I  have  witnessed,  there  was  paralysis, 
which  had  become  more  profound  with  each  accession.  It  is  therefore 
inexact  to  say,  as  do  some  writers,  that  the  paralysis  of  cerebral  con- 
gestion always  disappears  in  a  short  time. 

The  apoplectic  form  of  cerebral  congestion  is  more  common  than 
any  other  of  the  fully  developed  varieties,  about  one  half  of  all  the 
cases  being  of  this  type. 

b.  The  Paralytic  Form. — Like  the  apoplectic  variety,  this  may  be 
unpreceded  by  the  premonitory  symptoms  constituting  the  first  stage, 
but  usually  they  have  been  present.  The  loss  of  power  or  of  sensibil- 
ity, or  of  both,  may  be  very  circumscribed,  limited  to  a  single  group 
of  muscles  in  the  one  case,  or  a  small  portion  of  the  cutaneous  surface 
in  the  other,  or  one  entire  side,  or  both  sides  of  the  body,  may  be  in- 
volved. It  differs  from  the  apoplectic  form  in  no  essential  respect, 
except  that  there  is  no  loss  of  consciousness.     Its  onset  is  sudden. 


CEREBRAL   CONGESTION.  51 

c.  Tlie  Convulsive  Form. — This,  like  the  variety  just  described, 
may  come  on  suddenly,  or  may  be  preceded  by  premonitory  symptoms. 
The  phenomena  of  the  attack  do  not  generally  differ  from  those  attend- 
ant on  an  ordinary  epileptic  paroxysm,  except  that  there  is  never  an 
aura,  and  no  peculiar  cry,  such  as  is  so  often  met  with  in  pure  epilepsy. 
There  is  the  same  tonic  spasm,  followed  by  clonic  convulsions,  which 
may  or  may  not  be  confined  to  one  side  of  the  body,  and  which  may  or 
may  not  be  followed  by  temporary  or  long-continued  paralysis.  Stupor 
likewise  supervenes,  but  is  neither  of  so  long  a  duration  nor  so  pro- 
found as  in  true  epilepsy. 

In  other  cases,  and  especially  in  infants  or  young  children,  there  is 
no  loss  of  consciousness.  The  pain  in  the  head  is  intense,  the  pupils 
are  contracted  and  insensible  to  light ;  there  are  vomiting  and  accelera- 
tion of  tlie  pulse.  The  convulsive  movements,  which  may  be  either 
tonic  or  clonic,  or  both  alternately,  are  either  quite  general  or  confined 
to  a  single  limb  or  even  a  group  of  muscles. 

This  form  of  cerebral  congestion  is  never  developed  during  sleep, 
for  then  the  brain  contains  less  blood  than  when  the  individual  is  awake. 
It  may  occur  during  stupor  induced  by  certain  drugs,  constriction  of 
the  neck,  or  a  dependent  position  of  the  head  ;  but  stupor  is  not  sleep, 
although  the  two  conditions  are  frequently  confounded.  Convulsions 
occurring  during  ordinary  sleep  are  never  the  result  of  congestion. 
This  point  will  be  more  fully  considered  under  the  head  of  epilepsy. 

After  the  stupor  the  patient  may  feel  comparatively  well,  or  there 
may  be  delirium,  continuing  for  several  hours.  As  in  the  apoplectic 
form,  there  may  be  a  succession  of  attacks,  and  the  mind  and  physical 
power  of  the  patient  are  thereby  greatly  weakened. 

The  variety  under  consideration  is,  perhaps,  more  liable  to  occur  in 
individuals  past  the  age  of  forty,  though  I  have  witnessed  several  cases 
in  quite  young  persons.  It  is  not  often  met  with  in  old  age,  and,  when 
it  is,  is  generally  fatal,  probably  from  secondary  lesion.  A  majority 
of  the  cases  of  epileptiform  convulsions,  occurring  for  the  first  time  in 
persons  over  the  age  of  forty,  are  instances  of  the  convulsive  form  of 
cerebral  congestion. 

'/.  Tin  tfojiurijii-  Form. — This  form  will  be  more  fully  described 
under  the  head  of  passive  cerebral  congestion,  to  which  condition  it  is 

almost  entirely  restricted.     It  difTers  from  the  apoplectic  form  in  the 

circumstance  that   the  invasion  is  gradual  ;   and  from  this  and  the  para- 

lytic  in  the  fact  that  then-  is  no  paralysis,  although  the  limbs  may  he 

in  a  -laic  of  general  resolution.      The  chief  phenomena  are  pain  in  the 

head,  dilatation  of  the  pupils,  and  stupor. 

&  '/'//<■  Maniacal  Fbrm.-— This  variety,  though  not  bo  common  as 
either  of  the  others,  is  y el  not  infrequent.  It  is  characterized  by  an 
accession  of  mental  derangement  not  materially  different  from  that  in- 
dicative of  acute  mania.    The  delirium  is  of  a  very  active  character,  the 


52  DISEASES   OF   THE   BRAIN. 

eyes  are  suffused,  the  face  is  red,  the  head  hot,  the  motility  active,  and 
the  whole  manner,  character,  disposition,  and  mental  processes  are 
changed.  During  the  paroxysm,  the  patient  may  commit  some  act  of 
violence,  and  it  almost  always  happens  that  his  combative  proclivities 
are  aroused.     He  may  likewise  attempt  to  injure  himself. 

The  attack  may  come  on  with  great  suddenness.  In  the  case  of  a 
gentleman  recently  under  my  charge,  it  was  the  result  of  eating  a  hearty 
meal  in  a  great  hurry  at  a  railway  station.  A  few  minutes  after  his 
return  to  the  train,  he  was  attacked  with  furious  delirium,  during  which 
he  attempted  to  injure  himself  and  all  within  his  reach.  He  was  seized 
and  held,  but  continued,  as  far  as  he  was  able,  to  bite,  scratch,  and 
kick  at  those  who  were  near  him.  The  paroxysm  lasted  about  two 
hours.  He  then  fell  into  a  heavy  stupor,  from  which  he  did  not  arouse 
for  two  hours  longer.  For  several  days  his  mind  was  weak,  and  there 
was  numbness  in  various  parts  of  his  body.  Gradually,  however,  he 
regained  his  former  powers,  but  he  suffered  from  occasional  confusion 
of  thought  and  difficulty  of  speech,  with  headache  and  wakefulness,  for 
several  weeks. 

In  another  case — that  of  a  boy  thirteen  years  of  age — it  was  charac- 
terized by  paroxysms  of  maniacal  excitement,  during  which  the  subject 
attempted  to  bite  and  otherwise  to  injure  those  around  him,  indulging 
at  the  same  time  in  the  most  profane  and  obscene  language.  These 
seizures  took  place  about  once  a  week.  There  was  generally  a  distinct 
recollection  of  all  the  events  which  had  happened.  In  several  other 
cases,  the  seizures  were  the  result  of  malarial  poisoning,  and  were  ex- 
actly periodical  in  their  occurrence.  Paralysis,  as  in  the  other  forms, 
may  be  one  of  the  phenomena  of  this  variety  of  cerebral  congestion. 
Death  may  take  place  during  the  attack,  or  from  secondary  lesions 
afterward.1  What  is  called  temporary  insanity,  mania  ephemera,  or 
impulsive  insanity,  generally  depends  upon  cerebral  congestion.  The 
subject,  therefore,  is  of  vast  importance  in  its  medico-legal  relations." 

f.  The  Aphasia  Form. — The  inception  of  this  type  is  usually  very 
sudden.  There  may  or  may  not  be  the  accompaniments  of  pain  in  the 
head,  vertigo,  and  confusion  of  mind.  The  chief  symptom  is  the  im- 
pairment or  abolition  of  the  faculty  of  speech,  and  this  may  be  the 
only  phenomenon.  A.very  interesting  case  is  that  of  Prof.  Lordat, 
which  is  graphically  described  by  Trousseau.3  The  loss  of  speech  was 
at  first  complete,  but  was  entirely  regained  in  twelve  hours. 

'  The  whole  subject  of  cerebral  congestion  has  been  well  considered  by  Calmeil,  in  his 
"Traitc  des  Maladies  Inflammatoircs  du  Cervcau."     Paris,  1859. 

*  See  a  memoir  by  the  author,  entitled  "  A  Medico-Legal  Study  of  the  Case  of  Daniel 
McFarland,"  in  the  Journal  of  Psychological  Medicine  for  July,  1870;  also  published 
separately  by  D.  Appleton  &  Co.  New  York,  1870.  Also  a  paper  on  "Morbid  Impulse," 
Psychological  and  Medico-I<egal  Journal,  August,  1874. 

1  "  Lectures  on  Clinical  Medicine,"  etc.  Translated  by  P.  Victor  Bazire,  M.  D.  Lon- 
don, 1866,  p.  219. 


CEREBRAL  CONGESTION.  53 

Several  similar  instances  have  come  under  my  observation.  In  a 
case  at  this  time  under  my  charge,  the  patient,  a  lawyer,  was  suddenly 
deprived  of  all  power  of  speech,  after  passing  several  hours  in  very  in- 
tense study.  There  was  a  little  confusion  of  ideas,  but  neither  pain  nor 
vertigo.  There  was  loss  both  of  the  memory  of  words  and  of  the  power 
of  so  coordinating  the  muscles  of  speech  as  to  articulate.  There  was 
no  paralysis  anywhere.    Recovery  was  complete  in  less  than  six  hours. 

In  two  cases  occurring  in  my  own  practice,  the  patients  were  sud- 
denly rendered  aphasic  by  inhalation  of  the  nitrite  of  amyl.  The 
effect  continued  for  half  an  hour  in  one  case,  and  for  nearly  an  hour  in 
the  other,  after  all  the  other  phenomena  from  the  amyl  had  entirely 
disappeared. 

The  subject  of  aphasia  will  be  more  fully  considered  in  a  subse- 
quent part  of  this  work. 

It  is  quite  probable  that  certain  disturbances  of  the  sensory  organs, 
restricted  spasmodic  actions,  and  paralyses,  illusions,  and  hallucina- 
tions, intellectual,  emotional,  and  volitional  impulses  of  a  morbid  char- 
acter, and  other  abnormal  cerebral  manifestations,  to  some  of  which 
attention  has  been  directed,  are  the  results  of  localized  and  quite  lim- 
ited congestions  of  the  brain.  As  already  said,  however,  it  would  be 
premature  to  differentiate  these  with  any  attempt  at  exactness  till  our 
knowledge  of  the  various  sensory,  motor,  and  mental  centers  of  the 
brain  is  more  exact  than  it  is  at  present. 

Thibd  Stage. — This  period  may  be  considered  as  beginning  after 
the  immediate  effects  of  the  paroxysm,  whether  it  has  been  of  the  apo- 
plectio,  paralytic,  convulsive,  maniacal,  or  aphasic  form,  have  passed 
off.  It  is  characterized  by  feebleness  of  body  and  mind,  by  gastric  or 
intestinal  derangement,  by  pain  in  the  head,  with  transient  attacks  of 
igo,  and  occasionally  by  numbness  and  slight  paralysis  of  one  or 
more  of  the  Limbs.  Many  of  the  Bymptoms  met  with  in  the  first  stage 
are  again  found  in  this. 

But  the  principal  phenomena  aw  those  connected  with  secondary 
lesions,  such  as  inflammation,  abscess,  softening,  and  adventitious 
growths  of  various  kinds.  These  will  be  considered  under  their 
proper  heads.  It  must  not  be  forgotten  thai  one  circumstance  al- 
wayi  and   that  is,  the  proclivity  to  other  paroxysms  of  some 

one  of  the  lull y-develo|ied  form-. 

passive  <  1:1:1.1:1:  \i.  coiroj  snoxr. 

This  condition  i-  the  result  of  causes  which  increase  the  amount  of 
veiM.n-  blood  in  the  brain.  It  is  more  commonly  met  with  in  old  per- 
son- and  in  those  of  feeble  constitution.     Women  are  more  frequently 

affected  than  men. 

Symptoms.  Fraai  Stags. — As  in  active  cerebral  congestion,  there 
is  a  .premonitory  stage,  the  symptoms  of  which  are  similar  to  those 


54  DISEASES   OF   THE   BRAIN. 

previously  described.  There  is,  however,  a  tendency  to  stupor,  and 
the  other  phenomena  are,  in  the  main,  less  strongly  marked.  Vertigo, 
pain,  illusions,  hallucinations,  and  delusions,  are  nevertheless  generally 
present  at  one  time  or  another.  But  the  stupor,  or  tendency  to  som- 
nolence, is  the  most  prominent  feature,  and  the  sleep,  even  when  com- 
paratively natural,  is  attended  with  dreams,  unpleasant  or  even  fright- 
ful in  character. 

The  degree  of  congestion  may  be  suddenly  increased,  or,  what  is  a 
more  probable  sequence,  there  may  be  effusion  of  serum,  and  then  in 
either  case  the  second  stage,  exhibiting  itself  as  in  the  apoplectic,  the 
paralytic,  the  convulsive,  the  soporific,  the  maniacal,  or  the  aphasic 
form,  results. 

The  proportion  of  cases  of  passive  cerebral  congestion  which  pass 
to  the  second  stage  is  greater  than  in  the  active  form  of  the  affection, 
and  it  is  accordingly  a  more  serious  disease. 

Second  Stage,  a.  The  Apoplectic  Form. — In  this  variety  the 
onset  of  the  affection  is  sudden,  like  that  of  active  cerebral  congestion. 
The  loss  of  consciousness  is  generally  complete,  the  face  is  red,  the 
pupils  are  dilated  and  insensible  to  light,  the  respiration  is  stertorous, 
and  the  faeces  and  urine  may  be  passed  involuntarily.  The  action 
of  the  heart  is  slow  and  feeble,  and  the  pulse  corresponds  to  these 
facts.  Paralysis  may  be  general,  or  confined  to  a  lateral  half  of  the 
body. 

If  sensibility  returns,  there  are  pain  in  the  head,  vertigo,  tinnitus 
aurium,  generally  some  embarrassment  in  the  speech  from  lingual  pa- 
ralysis, and  more  or  less  loss  of  the  power  of  motion  in  other  parts  of 
the  body.  There  will  also  be  general  or  partial  ana3sthesia.  As  the 
condition  of  the  patient  improves,  these  symptoms  generally  disappear. 
Death,  however,  is  not  an  infrequent  sequence.  This  form  of  cerebral 
congestion  is  most  common  with  elderly  persons,  and  appears  to  be 
particularly  apt  to  attack  old  women. 

b.  The  Paralytic  Form. — This  does  not  differ  essentially  from  the 
apoplectic  form,  except  that  there  is  no  loss  of  consciousness,  the  pa- 
ralysis constituting  the  main  symptom.  It  may  be  either  sudden  or 
gradual  in  its  inception. 

c.  The  Convulsive  Form. — This  may  not  differ  materially  from,  the 
convulsive  form  of  active  congestion,  except  as  regards  increased  length 
of  the  fit  and  prolonged  stupor.  Generally,  however,  there  is  a  repeti- 
tion of  the  seizures,  and  I  am  led  to  believe,  from  my  experience,  that 
there  is  a  greater  tendency  to  biting  the  tongue.  Paralysis  is  a  more 
common  sequence,  and  is  of  longer  duration,  and  the  mind  appears  to 
suffer  more  seriously  and  at  an  earlier  period. 

d.  The  Soporific  Form. — The  first  symptom  observed  is  commonly 
a  general  numbness  and  indisposition  to  muscular  exertion.  The  drow- 
siness, which  has  probably  been  present  to  some  extent,  increases,  and 


CEREBRAL   CONGESTION.  55 

soon  becomes  the  most  notable  feature.  At  first,  it  is  easy  to  rouse 
the  patient  from  this  stupor,  but  it  gradually  becomes  more  profound 
and  overpowering,  until  at  last  a  persistent  comatose  condition  is 
reached.  The  faculties  of  the  mind  may,  in  the  earlier  stages,  be  ex- 
cited into  a  moderate  degree  of  activity  ;  but  with  the  advancing  coma 
they  are  no  longer  capable  of  being  manifested.  The  cutaneous  sensi- 
bility becomes  less  and  less,  the  urine  dribbles,  from  paralysis  of  the 
bladder  and  its  sphincter,  and  the  bowels,  if  not  obstinately  constipated, 
allow  their  contents  to  pass  involuntarily.  With  these  symptoms,  the 
pupils  are  dilated,  and,  as  long  as  sensibility  exists,  pain  in  the  head  is 
complained  of.  The  faculty  of  speech  is  impaired  at  an  early  period, 
but,  although  the  tongue  is  l'estrained  in  its  movements,  there  is  no 
actual  paralysis  of  this  or  any  other  muscle.  This  condition  may  last 
for  several  weeks,  and,  though  recovery  occasionally  takes  place,  this  is 
never  complete.     Death  is  the  more  usual  termination. 

e.  The  Maniacal  Form  is  not  often  met  with  in  passive  cerebral 
congestion,  and,  when  it  is,  the  delirium,  so  far  from  being  of  a  furious 
type,  is  low.  The  patient  mutters  to  himself  incoherently,  and  exhibits 
great  muscular  restlessness,  but  never  attempts  to  do  violence  to  him- 
self or  others.     Coma  often  occurs  as  a  sequence. 

f.  The  Aphasic  Form. — Aphasia  without  other  complication  is  not 
often  met  with  as  a  consequence  of  passive  cerebral  congestion.  Two 
instances  only  have  come  under  my  notice,  and  in  both  the  development 
was  much  slower  than  is  usually  the  case  in  the  active  form  of  the  affec- 
tion. In  both  of  these  there  was  disease  of  the  right  side  of  the  heart, 
manifested  by  mitral  and  tricuspid  regurgitation,  jugular  pulsation, 
great  fullness  of  the  veins  of  the  neck  and  I'a;  e, and  ascites  and  general 
anasarca.  The  loss  of  the  idea  of  language  was  complete  in  both  cases, 
and  persisted  for  about  forty-eight  hours.  There  was  no  paralysis, 
stupor,  or  convulsion,  and  but  Blight  pain.  The  ophthalmoscope  re- 
treated the  "\istence  of  great  turgescence  of  the  retinal  veins,  with  ve- 
nous pulsation. 

Causes. — The  causes  of  cerebral  Congestion  are  ■   of  the  active  form, 

those  influences  which  are  capable  of  Increasing  the  quantity  of  arterial 

blood  in  the  brain  :  of  the  passive,  those  which  produce  a  similar  effect 
upon  the  amount  of   venous  blood  circulating   in  the  re68els  within  the 

cranium.  The  causes  of  the  first  category  induce  activity  of  circulation, 
t  hose  of  t  hr  second  torpidil  v. 

The  causes  of  active  cerebral  congestion  may  either,  by  their  grad- 
ual   operation,  initiate    the    premonitory  Stage,  or   they    may    suddenly 

induce  tin  development  of  this  stage  into  one  or  other  of  the  varieties 
already  described  as  constituting  the  second  -ta'_r<'-  Among  them  is 
temperature  either  very  high  or  very  low.     Thus,  the  disease  is  more 

frequenl   in  hot  climates  than  in  those  of  more  temperate  character,  and 

in  the  summer  months  than  in  the  spring  or  autumn.     It  is.  however, 


56  DISEASES   OF  THE  BRAIN. 

more  common  in  very  cold  than  in  warm  weather.  Thus  Andral,  of 
one  hundred  and  fourteen  cases,  found  that  twenty-six  occurred  in  sum- 
mer and  fifty  in  winter.  My  own  experience  is  to  the  same  effect,  as 
will  be  seen  from  the  following  table,  which  embraces  the  cases  in  my 
private  practice  in  the  city  of  New  York  during  a  period  of  five  years, 
beginning  January,  1865,  and  ending  December,  1870  : 

January 66  July 68 

February 64  August 74 

March 50  September 27 

April 39  October 31 

May 42  November 52 

June 37  December 72 

Total 622 

An  examination  of  this  table  shows  that  one  hundred  and  ten  cases 
occurred  in  the  autumn  months,  one  hundred  and  thirty-one  in  the 
spring,  one  hundred  and  seventy-nine  in  summer,  and  two  hundred  and 
two  in  winter.     All  my  subsequent  experience  is  to  the  same  effect. 

Passive  cerebral  congestion  is  very  much  more  frequent  in  cold 
than  in  warm  weather. 

The  direct  rays  of  the  sun  are  capable  of  producing  sudden  attacks 
(insolatio),  of  which  congestion  is  a  prominent  feature,  but  which  re- 
quire separate  consideration  ;  and  it  is  not  uncommon  for  artisans, 
whose  heads  are  exposed  to  heat  from  furnaces,  to  suffer  in  a  similar 
manner. 

Some  authors  contend  that  certain  winds  increase  the  liability  to 
cerebral  congestion.  Leuret,  quoted  by  Mosmant,1  could  attribute  an 
epidemic  of  cerebral  congestion,  which  appeared  at  Charenton,  to  noth- 
ing but  a  long-continued  wind  from  the  northwest.  The  supposition 
that  atmospheric  electricity  is  a  causative  influence  rests  upon  nothing 
but  hypothesis. 

Unhealthy  situations,  such  as  those  subject  to  the  influence  of  ma- 
laria and  to  noxious  emanations  of  any  kind,  and  which  are  not  well 
ventilated,  also  predispose  to  attacks  of  cerebral  congestion. 

The  ingestion  of  a  large  quantity  of  food  into  the  stomach  may 
occasion  passive  congestion,  by  the  pressure  which  the  distended 
organ  makes  upon  the  large  veins  of  the  abdomen.  Rapid  eating, 
even  though  the  quantity  of  food  be  moderate,  may  cause  the  active 
form  of  the  affection  by  some  influence  exerted  through  the  sympa- 
thetic system. 

Sudden  and  violent  physical  exertion,  especially  if  made  in  the 
stooping  posture,  is  very  liable  to  induce  cerebral  congestion.  Child- 
birth is  an  instance  in  point,  and  I  have  known  several  cases  to  be 
caused  by  severe  straining  in  the  water-closet.     The  constipation  of 

1  "  Essai  sur  la  Congestion  Cerebralc."     Paris,  1858. 


CEREBRAL   CONGESTION.  57 

the  bowels  rendering  such  efforts  at  defecation  necessary  is  itself  pro- 
ductive of  the  disease. 

A  dependent  position  of  the  head  and  constriction  of  the  neck  from 
the  dress  are  also,  by  impeding  the  return  of  blood  from  the  head,  liable 
to  induce  congestion  of  the  passive  form. 

Certain  articles  of  food  and  medicine,  such  as  spices,  alcoholic 
liquors,  opium,  belladonna,  quinine,  etc.,  act  either  by  augmenting  the 
power  of  the  heart,  or  by  their  effect  on  the  sympathetic,  paralyzing 
the  vaso-motor  nerves,  and  thus  increasing  the  caliber  of  the  cerebral 
blood-vessels.  In  this  connection,  the  influence  of  the  nitrite  of  amyl, 
when  inhaled  to  increase  the  quantity  of  blood  in  the  brain,  may  be 
cited  as  an  instance  of  this  latter  power. 

Tumors  in  the  neck,  or  in  other  parts  of  the  body  where  the  return 
of  blood  from  the  head  may  be  impeded  by  their  pressure,  likewise 
cause  congestion.  Other  causes  are  to  be  found  in  certain  diseases, 
as  fevers  of  various  kinds,  erysipelas,  disorders  of  menstruation,  the 
suppression  of  hemorrhagic  or  other  discharges  ;  local  affections  of 
the  brain,  as  embolus,  thrombosis,  tubercle  or  apoplectic  clots,  and 
sympathetically  by  worms  in  the  intestinal  canal,  or  irritation  existing 
in  other  portions  of  the  system.  Hypertrophy  of  the  left  side  of  the 
heart  is  a  common  cause  of  active  cerebral  congestion  ;  and  any  affec- 
tion of  the  right  side  of  this  organ,  tending  to  impede  the  return  of 
the  venous  blood,  is  an  important  factor  in  giving  rise  to  the  passive 
form  of  the  affection  under  notice. 

But  the  most  influential  and  common  causes  of  cerebral  hyperemia, 
and  eventually  of  congestion,  are  to  be  found  in  long-continued  intel- 
lectual exertion,  mental  anxiety,  or  sudden,  violent,  or  prolonged  emo- 
tional disturbance.  It  is  from  the  action  of  such  factors  that  the  pre- 
monitory symptoms  are  generally  induced,  though  they  may,  especially 
those  embraced  in  the  last-named  category,  immediately  develop  a 
fully  formed  attack.  The  fact  that  cerebral  exercise  increases  the 
amount  of  blood  in  the  head  is  made  evident  to  all  of  us  at  times,  by 

the  distention  of  the  superficial  vessels,  the  suffusion  of  the  eyes,  the 
heal    and    pain    which   we    feel    when   we   have   overtasked    our   brains. 

Cerebral  action  is  always  attended  with  hyperemia,  jusl  as  is  the 

activity  of  the  liver,  the  kidneys,  or  other  organs.  Active  cerebral 
Congestion  is  thus  induced,  and  is,  within  certain  limits,  perfectly  nor- 
mal.     Bui    these   limits  are   liable   to   be  exceeded  - -and,  in   thisacti\e 

period  of  the  world's  history,  of  ten  are — and  then  the  condition  de- 
scribed as  the  firsl  stage  of  con  gestion  is  established.  The  vessels,  from 
continued  over-distention,  lose  their  contractility,  jusl  as  I  have  said 
does  the  India-rubber  band,  used  to  keep  a  bundle  of  lett<  ra  together, 
when  the  package  is  too  large,  or  it  has  been  kept  Btretched  for  a 
longtime.  An  additional  disturbing  force,  heat,  cold,  an  overloaded 
stomach,  increased    mental   labor,  emotional   excitement,  or   any  of 


58  DISEASES   OF   THE   BRAIN. 

the  causes  mentioned,  may  suddenly  evolve  a  fully  developed  par- 
oxysm. 

Emotion  acts  in  a  similar  manner,  though,  as  has  been  said,  often 
with  more  suddenness.  The  emotions  of  shame,  of  anger,  and  others 
cause  the  face  to  become  red  from  dilatation  of  the  blood-vessels,  and 
a  like  effect  is  produced  in  the  vessels  within  the  cranium.  If  the 
emotion  is  very  strong  or  lasting,  a  correspondingly  increased  hyper- 
aunia  results. 

There  are  certain  circumstances  which  render  the  action  of  the 
causes  specified  more  effectual  or  powerful.  These  are  inherent  in 
the  individual,  and  may  be  classed  as  predisposing  causes.  Among 
them  are  sex,  the  disease  being  more  common  in  males  ;  age,  it  being 
more  frequently  met  with  in  middle-aged  or  old  persons  ;  hereditary 
influence  ;  hypertrophy  of  the  left  ventricle  of  the  heart,  by  which 
the  flow  of  blood  to  the  head  is  directly  increased  ;  dilatation  of  the 
right  ventricle,  by  which  its  power  is  diminished,  and  the  return  of 
blood  from  the  head  impeded  ;  insufficiency  of  the  auriculo-ventricular 
valves,  or  constriction  at  the  auricular  or  ventricular  orifices  on  the 
same  side,  by  which  a  similar  result  is  produced,  and  perhaps,  though 
this  point  is  by  no  means  established,  shortness  of  the  neck. 

Diagnosis. — Cerebral  congestion  may  be  confounded  with  cerebral 
haemorrhage,  meningeal  haemorrhage,  embolism,  thrombosis,  softening, 
epilepsy,  urinaemia,  stomachal  vertigo,  auditory  vertigo,  and  with  the 
very  opposite  condition,  cerebral  anaemia.  From  each  of  these  affec- 
tions it  is,  however,  distinguished  by  well-marked  characteristics. 

The  premonitory  symptoms  are  not  liable  to  be  mistaken  for  cere- 
bral haemorrhage,  but  this  error  may  be  made  as  regards  the  second 
stage.  The  apoplectic  form  is,  however,  distinguished  from  apoplexy 
due  to  extravasation,  by  the  fact  that  in  it  the  loss  of  intelligence  is 
rarely  complete,  and  that,  when  it  is  so,  the  mind  is  dormant  but  for  a 
few  moments  ;  that  sensibility  and  the  power  of  motion  are  never  alto- 
gether abolished  ;  that  coma,  when  present,  is  rarely  profound  ;  that 
the  paralysis,  when  it  exists,  is  seldom  limited  to  one  side  of  the  body  ; 
by  the  general  absence  of  stertor,  and  puffing  of  the  lips  and,  cheeks 
in  breathing  ;  and  by  the  short  duration  of  the  symptoms. 

From  meningeal  haemorrhage,  it  is  discriminated  by  the  comparative 
lightness  of  the  symptoms,  and  by  the  fact  that  they  do  not  progres- 
sively augment  in  severity  or  intermit  in  violence. 

Cerebral  congestion  and  embolism  present  some  features  in  com- 
mon, and  it  is  therefore  occasionally  difficult  to  distinguish  them.  In 
the  former,  however,  the  pulse  is  slow  and  the  respiration  regular  and 
deep  ;  in  the  latter,  the  pulse  is  more  rapid,  is  often  irregular,  as  is  also 
the  respiration  ;  in  the  former,  there  is  increased  heat  of  the  head  ;  in 
the  latter,  the  temperature  of  this  part  of  the  body  is  unchanged  ;  in 
cerebral  congestion  the  symptoms  are  transient  ;  in  embolism  they  are 


CEREBRAL   CONGESTION.  59 

more  lasting  ;  in  the  former  there  is  often  a  distinct  premonitory 
stage  ;  in  the  latter,  the  attack  always  takes  place  without  a  moment's 
warning.  In  the  former,  though  there  may  be  cardiac  difficulties,  they 
are  different  from  those  predisposing  to  embolism,  which  are  consecu- 
tive to  endocarditis — generally  rheumatic — and  which  implicate  the 
semi-lunar  or  mitral  valves,  and  in  the  fact  that  recovery  from  an  at- 
tack of  cerebral  congestion  is  generally  complete,  which  is  rarely  the 
case  in  embolism. 

From  thrombosis,  cerebral  congestion  is  diagnosticated  by  the  cir- 
cumstances that  in  the  former  the  progress  of  the  disease  is  slow,  that 
there  is  usually  well-marked  paralysis  from  the  beginning  ;  that  the  phe- 
nomena indicating  mental  disturbance  are  more  strongly  pronounced  ; 
that  the  articulation  and  memory  for  words  are  more  permanently  af- 
fected ;  and,  notwithstanding  occasional  remissions,  by  the  persistency 
and  gradual  advance  of  the  symptoms. 

In  softening  there  are  often  a  sudden  loss  of  consciousness,  persist- 
ent hemiplegia,  and  death  in  a  few  days.  Again,  there  is  delirium 
without  paralysis  or  convulsions,  and  in  other  cases  there  is  a  gradual 
accession  of  the  symptoms.  This  latter  is  the  only  form  liable  to  be 
mistaken  for  cerebral  congestion.  It  is  attended  with  headache,  feeble- 
ness of  intellect,  and  a  gradually  advancing  paralysis  generally,  begin- 
ning in  one  of  the  lower  extremities,  and  extending  to  the  whole  of 
(me  side  of  the  body.  The  speech  is  always  seriously  impaired,  and 
the  mental  disorder  is  of  a  far  graver  character  than  that  due  to  cere- 
bral congestion.  The  gradual  advance  of  the  affection  to  a  fatal  ter- 
minal ion  is  also  a  characteristic  circumstance. 

With  urimcmia,  cerebral  congestion  may  be  confounded,  if  only  the 
more  obvious  head  symptoms  be  taken  into  consideration.  The  his- 
tory of  the  case  and  full  inquiry  will  always,  however,  enable  the  proper 
discrimination  to  be  made.  Thus,  in  urinainia  the  existence  of  kidney 
disease,  as  evidenced  by  a  chemical  and  microscopical  examination  of 
the  urine,  the  anasarca  of  the  face  or  limbs,  and  the  repeated  attacks 
of  convulsions  and  coma,  will  he  sufficient  diagnostic  marks. 

From  epilepsy,  cerebral  congestion  is  distinguished  by  the  fact  that 
the  former  is  not  preceded  by  the  group  of  Bymptoms  constituting  the 
first  stage  of  congestion  ;  that  the  congestion  of  the  vessels  of  the  face 

and  neck  is  preceded  by  a  death-like  paleness  ;  that  an  aura  i-  often 
present  :  that  there  mas  be  a  peculiar  cry  J  thai  the  patient  .Iocs  not 
Stagger  and  fall    slowly    l<>    the    ground,  but  drops  as  if  knocked  down 

by  a  severe  blow  ;  and  that  the  tongue  Lfl  frequently  bitten.  The  re- 
verse i-^  the  case  u  regards  all  these  phenomena  in  cerebral  congestion. 
Nevertheless,  so  accurate  and  experienced  an  observer  as  Trousseau, 
in  his  clinical  lecture  on  "  Apoplectiform  Cerebral  <  longestion  in  its  Re- 
lations to  Epilepsy  and  Eclampsia,"1  confounds  the  two  conditions. 
1  "OUnique  ftlidicale,"  tomeii.,  p.  60.    Also  Bazire's  Translation,  I.  mdon,  1866,  p.  ID. 


GO  DISEASES   OF   THE   BRAIN. 

Trousseau's  views  on  this  subject  do  not,  however,  appear  to  be  accepted 
by  any  large  number  of  medical  authorities.  Epileptic  vertigo  is,  as 
will  be  shown  at  a  proper  place,  a  very  different  affection  from  any 
form  of  cerebral  congestion,  and  is  not  likely  to  be  confounded  with 
it.  Epileptic  mania  has,  likewise,  very  few  points  in  common  with  the 
disease  under  consideration. 

In  stomachal  vertigo  the  attacks  of  dizziness  are  often  severe,  but 
they  are  clearly  associated  with  gastric  derangement,  and  only  occur 
while  the  stomach  is  digesting  its  contents.  Other  symptoms  of  dys- 
pepsia will  also  be  noticed,  while  the  mental  and  physical  disturbances, 
which  constitute  so  prominent  a  feature  of  cerebral  congestion,  are  ab- 
sent.    The  distinction,  however,  is  not  always  made. 

In  auditory  vertigo,  or  Meniere's  disease,  the  dizziness  is  accompa- 
nied with  aural  troubles,  such  as  deafness  and  tinnitus  ;  the  face  is  pale  ; 
and  there  is  almost  invariably  vomiting,  or  at  least  intense  nausea. 
Moreover,  when  there  is  loss  of  consciousness,  the  premonitory  symp- 
toms are  not  such  as  precede  the  second  stage  of  cerebral  congestion, 
but  are  connected  with  the  function  of  audition. 

From  cerebral  anrcmia,  the  first  stage  of  congestion  is  frequently  not 
clearly  distinguished,  and  I  have  seen  sevei'al  cases  in  which  patients 
had  been  treated  for  the  one  condition  when  the  other  was  indubitably 
present.  In  both  there  are  headache,  sense  of  constriction,  vertigo, 
noises  in  the  ears,  numbness,  mental  confusion,  loss  of  memory,  inapti- 
tude for  labor  of  any  kind,  and  at  times  loss  of  consciousness.  But  in 
anoemia  the  face  is  not  flushed,  the  carotid  and  temporal  arteries  do  not 
throb  with  violence  ;  the  pulse  is  quick,  feeble,  and  irregular,  the  res- 
piration is  hurried,  the  pupils  are  dilated,  there  are  bellows  murmurs 
at  the  base  of  the  heart  and  in  the  veins  of  the  neck,  and  the  general 
aspect  of  the  patient  is  not  of  that  rugged  appearance  so  generally 
associated  with  cerebral  congestion.  In  the  syncope  of  cerebral  anfe- 
mia,  the  paleness  of  the  face,  coldness  of  the  skin,  and  feebleness  of 
the  heart's  action,  will  serve  to  draw  the  line  between  it  and  the  apo- 
plectic form  of  congestion.  The  ophthalmoscope  will  at  all  stages 
prove  of  great  value  in  the  diagnosis. 

Prognosis. — The  prognosis  is  materially  modified,  according  to  the 
stage  of  the  disease  present  when  the  patient  is  seen,  and  the  form  of 
attack  from  which  he  may  be  suffering.  Active  cerebral  congestion  is 
a  more  favorable  type  than  the  passive.  If  the  affection  has  not  gone 
beyond  the  first  stage,  a  fortunate  issue  may  safely  be  predicted  under 
the  use  of  suitable  medical  treatment  ;  but,  if,  through  neglect  or  im- 
proper treatment,  or  indiscretion  on  the  part  of  the  patient,  the  disease 
becomes  fully  developed,  the  prognosis  is  much  more  grave.  I  have 
never  known  a  death  to  take  place  in  any  patient  from  this  disease 
during  the  premonitory  stage.  The  apoplectic  and  soporific  forms  are 
the  most  grave,  and  the  prognosis  is  rendered  more  unfavorable  with 


CEREBRAL   CONGESTION.  61 

each  attack.  The  epileptic  form  is  ordinarily  not  dangerous  to  life, 
nor  is  the  paralytic,  maniacal,  or  the  aphasic,  except  in  old  persons. 
Occasionally,  however,  even  in  young  and  robust  patients,  death  en- 
sues during  the  paroxysms  of  these  forms. 

The  liability  to  secondary  lesions,  such  as  softening,  cerebritis,  haem- 
orrhage, aneurisms,  general  paralysis,  etc.,  must  be  taken  into  account 
when  forming  a  prognosis.  The  more  frequent  the  paroxysms  of  any 
form,  the  greater  the  risk  of  some  such  finality. 

The  habits  of  the  patient  are  also  important  elements  in  forming 
an  opinion  in  regard  to  the  ultimate  result.  If  these  are  bad,  and  are 
persisted  in,  the  probability  is  that  no  treatment  will  be  of  much  avail 
in  preventing  a  recurrence.  Moreover, by  such  a  condition  of  the  brain 
as  the  excessive  use  of  alcohol,  inordinate  mental  exertion,  or  contin- 
ual emotional  excitement  induces,  the  chance  of  escaping  some  sec- 
ondary morbid  process  is  very  much  lessened. 

Of  the  one  hundred  and  seven  fully  developed  cases  which  have 
been  under  my  observation  during  the  past  eight  years,  there  were 
eighteen  deaths  ;  seven  from  the  apoplectic  form,  all  after  repeated 
attacks  ;  three  from  the  maniacal,  one  of  which  was  that  of  a  young 
man  about  thirty  years  of  age  ;  and  seven  from  secondary  lesions.  Of 
these  latter,  four  were  from  softening,  one  from  cerebritis,  one  from 
hemorrhage,  and  one  from  general  paralysis. 

Morbid  Anatomy. — There  are  certain  appearances  seen  in  the  brains 
of  those  who  have  died  of  cerebral  congestion  which  are  characteristic, 
although  it  must  be  confessed  that  some  or  all  of  them  are  occasionally 
absent.      These  arc  : 

An  increased  size  of  the  capillaries  ami  large  blood-vessels,  both  of 

the  brain  ami  the  pia  mater.  It  thus  happens  that,  when  a  section  of 
the  brain  is  made,  the  red  points  ordinarily  seen  are  larger  and  more 
numerous  than  usual,  ami  that  the  pia  mater  presents  in  spots,  or 
throughout  it-  extent;  a  red  or  rose-colored  appearance. 

The  w  hitc  matter  of  the  brain  is  increased  in  Consistence  ami  den- 
sity, and  the  gray  matter  is  red,  or  even  riolet  in  hue. 

There  is  sometimes  a  large  quantity  of  Bubarachnoidean  effusion  j 

the  ventricles  mav  contain  au  excessive  amount  of  fluid,  and  the  cho- 
roid plexuses  are  ofien  en  la  rge<  1. 

[f  there  have  been  repeated  attacks  of  cerebral  congestion,  it  is 
not   unusual  t«»  find,  by  microscopical  examination,  little  granules  of 

ha  iii.it  iii  ill  contact  with  the  blood-VCSSels.  The  same  means  of  explo- 
ration shows  the  minuter  capillaries  t . »  be  more  than  naturally  tortuous, 
ami  to  have  little  aiieiirismal  swellings.  These  may  or  may  not  involve 
the    whole    circumference    of    the    ve»el.      Their    presence    ami    import 

were  first  pointed  out  by  Laborde.' 

1  "La  ramollissement  ct  congestion  du  cervcau  princlpaleinant  considers  chcz  de 

vii  ilhnJ."     Paris,  180C. 


62  DISEASES   OF   THE   BRAIN. 

On  making  a  transverse  section  of  the  hemisphere,  a  cribriform 
appearance  is  seen,  if  the  patient  has  repeatedly  suffered  from  attacks 
of  cerebral  congestion,  and  especially  if  he  be  advanced  in  years.  This 
is  due  to  the  presence  of  numerous  little  holes  with  sharply-defined 
margins.  The  brain-tissue  bounding  these  is  generally  without  mate- 
rial change,  either  in  color  or  consistence.  This  condition,  called  by 
Durand-Fardel,1  to  whom  the  credit  of  first  describing  it  is  usually 
given,  "  l'etat  crible,"  is  supposed  to  be  due  to  the  fact  that  the  vessels 
have  been  so  distended  during  life  as  to  press  with  increased  force 
upon  the  perivascular  tissue,  and  that,  shrinking  after  death,  they  no 
longer  fill  their  former  space,  which  remains  empty.  Calmeil1  was 
the  first  to  notice  this  condition.  He  has  very  often  found,  in  maniacs, 
the  white  substance  rendered  cribriform  by  vessels  distended  with 
blood,  sometimes  empty,  but  always  greatly  dilated.  This  state,  al- 
though frequently  met  with  in  congestion,  is  not  uncommon  in  other 
pathological  conditions,  such  as  the  several  forms  of  softening,  of 
which,  however,  congestion  is  often  the  first  stage. 

Durand-Fardel3  calls  attention  to  the  fact  that,  on  making  sections 
of  the  medullary  substance  of  the  cerebrum,  it  is  not  uncommon  to  find 
in  cases  of  congestion  rose-colored  patches  scattered  throughout  its 
substance.  On  examining  these  with  a  lens,  they  are  seen  to  consist  of 
a  large  number  of  delicate  vessels  partially  injected.  I  have  never  wit- 
nessed this  appearance,  except  in  one  instance,  nor  is  it  noticed  by  au- 
thors on  the  subject  generally. 

If  the  congestion  has  been  severe  or  long  continued,  the  convolutions 
may  be  to  a  considerable  extent  obliterated  by  the  compression  of  the 
brain  against  the  internal  wall  of  the  cranium.  At  the  same  time,  the 
membranes  of  the  brain  are  rendered  dry  and  viscous  from  the  pressure 
to  which  they  have  been  subjected. 

In  passive  congestion  the  sinuses  of  the  dura  mater  are  the  chief 
seats  of  vascular  turgescence  ;  the  veins  generally  are  distended,  and 
there  is  ordinarily  a  greater  amount  of  serous  effusion  in  the  subarach- 
noid space  than  in  the  active  variety  of  the  disease. 

Pathology. — It  is  almost  useless  at  this  day  to  discuss  the  question 
of  the  possibility  of  the  quantity  of  blood  in  the  brain  being  subject  to 
variation.  Still,  it  may  be  interesting  to  recall  briefly  the  facts  which 
establish  the  affirmative  in  the  matter. 

In  the  cases  of  infants,  in  whom  the  anterior  fontanelle  is  still  open, 
the  scalp  is  seen  to  be  elevated  above  the  level  of  the  skull  when  the 
head  is  dependent,  and  depressed  when  the  head  is  elevated. 

The  same  fact  is  observed  in  persons  who  have  suffered  injury  of  the 

1  "Traiti  pratique  des  maladie3  des  vieillards."  Paris,  1854,  and  deuxieme  Edition, 
1873. 

4  "  De  la  paralysis  conside>dc  chez  les  aliened,"  etc.     Paris,  1826. 
3  Op.  cit.,  Paris,  1873,  p.  21. 


CEREBRAL   CONGESTION.  63 

skull,  involving  the  loss  of  a  portion  of  its  substance.  During  strong 
emotional  excitement,  or  the  action  of  any  cause  capable  of  increasing 
the  force  of  the  circulation,  the  scalp  is  elevated.  From  the  action  of 
opposite  causes  it  is  depressed.  Both  in  infants  and  in  persons  who 
have  received  injuries  such  as  those  cited,  the  scalp  is  seen  to  be  de- 
pressed during  sleep,  and  to  rise  as  soon  as  the  individual  awakes. 

A  dependent  position  of  the  head  causes  a  sensation  of  fullness,  or 
even  pain,  and  blood  may  flow  from  the  nostrils.  The  eyes  are  observed 
to  be  "  bloodshot,"  and  the  countenance  indicates  congestion.  A  tu- 
mor, a  ligature,  or  any  other  cause  capable  of  exerting  pressure  on  the 
jugular  veins,  will  produce  like  effects.  Ophthalmoscopic  examination 
under  such  circumstances  shows  the  veins  of  the  retina  to  be  enlarged, 
indicating  that  an  obstruction  exists  to  the  return  of  blood  through  the 
sinuses  and  veins  within  the  cranium.  Post-mortem  examination  of 
pei'sons  dying,  who,  during  life,  have  suffered  interruption  to  the  per- 
fect return  of  blood  from  the  head,  reveals  the  existence  of  intracranial 
congestion.  Animals,  subjected  to  experiments  calculated  to  act  in  the 
manner  stated,  are  after  death  found  to  have  congested  brains. 

In  animals  bled  to  death  the  brain  is  found  anaemic  to  an  extreme 
degree. 

Direct  experiment  still  more  positively  establishes  the  fact  under 
consideration.  If  a  portion  of  the  skull  of  an  animal  be  removed,  and 
the  aperture  be  then  securely  closed  with  a  watch-glass,  the  vessels  will 
be  seen  to  enlarge  and  contract  according  to  the  cause  brought  into 
action,  and  the  brain  will  be  correspondingly  elevated  or  depressed. 

By  means  of  an  instrument,  devised,  independently  of  each  oilier,  by 
Dr.  S.  Weir  Mitchell  ami  myself,  the  degree  <>f  pressure  within  the  cra- 
nium can  lie  accurately  measured.  It  is  thus  seen  that  the  quantity  of 
blood  circulating  in  the  brain  undergoes  material  variation.1 

The  anatomical  arrangement  of  the  blood-vessels  of  the  cerebral  tis- 
sue  is  such  as  to  admit  of  an  enlargement  of  their  calibre  without   neces- 

Barily  subjecting  the  perivascular  substance  to  pressure.  Robin' dis- 
covered the  existence  of  sheaths  around  these  vessels,  and  his  observa- 
tions were  subsequently  confirmed  by  His,3  who  ascertained  that  the 
same  arrangement  exists  in  the  Bpinal  cord.  According  to  His,  "  Fine 
transverse  sections  of  a  hardened  brain,  having  its  vessels  injected  or 
otherwise,  show  that  all  the  blood-vessels,  arteries,  veins,  and  even 
capillaries,  are  Burrounded  by  a  dear  Bpace,  broadest  in  the  case  of  the 

1  For  a  more  complete  argument  on  the  subject,  and  for  a  statement  In  detail  <>f  the 
experiments  of  Mr,  Durham  and  myself  on  this  point,  the  reader  i-  referred  to  the  author's 
monograph,  "Sleep  and  it.-  Derangements."     Philadelphia:  J.  B.  Lippinootl  A 
Tin-  cephalo-hsmometer  referred  t<>  In  the  text  Is  described  in  that  work  (Appendix),  and 
also  in  the  introduction  to  this  treatise. 

,ml  ■!.  1 1  physioloffie  d»  Phomm*  <t  dea  animaux,  18S9,  ]>.  527. 

8  "  Zeitachrift  fur  Wissenschaftliche  Zoologie,"  1866,  B,  xr.,  quoted  In  tits  Journal  <•/ 
Anatomy  nml  Physiology.    Translation  by  Dr,  Bastian. 


64  DISEASES   OF   THE   BRAIN. 

larger  vessels,  but  in  all  cases  quite  sharply  defined  externally.  In 
transverse  sections  the  vessels  are  seen  to  be  surrounded  by  a  ring-like 
space,  and  in  parallel  sections  the  space  is  seen  on  each  side  of  the 
trunk  of  the  vessel,  and  follows  it  in  all  its  ramifications." 

These  perivascular  canals  are  lined  by  a  hyaline  membrane,  and  are 
capable  of  being  injected,  and,  in  cases  of  chronic  congestion,  may  be- 
come permanently  enlarged,  so  as  to  cause  the  appearance  referred  to 
under  the  heading  of  morbid  anatomy. 

The  pathology  of  the  subject  receives  further  elucidation  from  a  con- 
sideration of  the  causes  capable  of  giving  rise  to  cerebral  congestion, 
and  which  have  been  already  mentioned  in  detail. 

Treatment. — Recollecting  the  two  grand  forms  of  cerebral  conges- 
tion, the  principles  which  should  guide  us  in  treatment  will  be  clearly 
apparent.  In  the  active,  type  of  the  disease,  the  force  of  the  cerebral 
circulation  and  the  quantity  of  blood  in  the  blood-vessels  of  the  brain 
are  to  be'lessened  ;  in  the  passive  variety,  the  force  of  the  circulation 
is  to  be  increased,  and  at  the  same  time  the  accumulation  of  blood  in 
the  veins  to  be  diminished.  In  the  active  form  of  this  affection,  the 
abstraction  of  blood  from  the  arm  was  formerly  very  generally  practised, 
but  is  now  rarely  perfomed.  I  have  never  seen  a  case  in  which  it  was 
required.  Local  bleeding  is  more  generally  applicable,  and  a  few  cups 
to  the  nape  of  the  neck  will  often  afford  marked  relief.  Leeches  to  the 
temples  are  also  useful,  though  they  are  preferably  applied  just  inside 
the  nostrils.  I  have  many  times  witnessed  the  most  satisfactory  results 
from  a  couple  of  leeches  thus  used,  and  from  accidental  nasal  haemor- 
rhage. 

The  application  of  the  actual  cautery  to  the  nape  of  the  neck  is 
also  a  measure  of  value,  especially  in  the  earlier  stages.  It  is  prefer- 
able, I  think,  to  any  other  form  of  counter-irritation,  and,  when  prop- 
erlv  done,  is  not  at  all  painful.  It  seems  to  have  a  positive  and,  in 
some  cases,  an  immediate  influence  in  diminishing  the  calibre  of  the 
cerebral  arteries. 

Cold  is  another  very  useful  agent  in  the  treatment.  It  may  be  ap- 
plied to  the  nape  of  the  neck,  or  directly  to  the  cranium,  either  as  very 
cold  water  or  in  the  form  of  ice. 

The  advantages  of  position  should  also  be  brought  to  bear.  The 
head  should  be  kept  elevated,  especially  during  sleep,  and  no  severe 
muscular  exertion  should  be  taken  while  stooping. 

The  clothing  should  be  kept  loose  about  the  neck.  As  a  derivative, 
a  mustard-plaster  applied  to  the  epigastrium  is  often  of  service  ;  and 
the  same  may  be  said  of  warm  or  even  hot  water  to  the  feet.  Blis- 
ters I  rarely  employ,  though  I  have  occasionally  done  so  with  ad- 
vantage. 

The  constant  galvanic  current  possesses  the  power  of  contracting 
the  cerebral  blood-vessels,  when  so  used  as  to  stimulate  the  sympathetic 


CEREBRAL   CONGESTION.  65 

nerve.  For  this  purpose,  one  pole  should  be  placed  over  this  nerve  in 
the  neck,  and  the  other  on  the  back  of  the  neck,  as  low  down  as  the 
seventh  cervical  vertebra.  The  current  from  about  fifteen  Smee's  cells 
is  sufficient,  and  it  should  not  be  allowed  to  act  for  more  than  two 
minutes.  If  extreme  vertigo  be  produced,  the  number  of  cells  should 
be  lessened.  This  property  of  the  primary  current  was  first  pointed  out 
by  Bernard,  Waller,  and  Budge,  but  its  demonstration  by  the  ophthal- 
moscope was  first  made  by  myself.  Observation  with  this  instrument, 
while  the  current  is  acting,  shows  that  the  vessels  of  the  retina  con- 
tract, and  hence  there  can  be  no  doubt  that  the  result  is  produced 
upon  those  of  the  brain.  A  similar  effect  is  caused  by  passing  the 
current  directly  through  the  brain,  the  poles  being  applied  to  the 
mastoid  processes.  A  slight  feeling  of  vertigo  follows  both  when  the 
circuit  is  closed  and  opened.  The  good  effects  of  this  practice  are  well 
marked,  a  few  applications  being  often  sufficient  to  abolish  the  vertigo 
and  unpleasant  feelings  in  the  head,  and  to  restore  mental  and  physical 
activity. 

Of  internal  remedies  the  number  is  not  large,  and  those  which  it  is 
advisable  to  employ  are  generally  effectual,  with  or  without  the  exter- 
nal measures  mentioned,  in  entirely  relieving  the  patient. 

First  among  these  must  be  placed  the  bromide  of  potassium.  Sev- 
eral years  ago  I  pointed  out  the  value  of  this  medicine,  and  explained 
the  rationale  of  its  action.  As  others  have  since  claimed  the  discovery 
as  their  own,  I  hope  I  may  be  excused  for  quoting  the  following  pas- 
eagc  from  a  memoir  upon  an  analogous  subject,1  in  which  the  action 
of  the  bromide  is  clearly  indicated  : 

"  Bromide  of  potassium  can  almost  always  be  used  with  advantage 
to  diminish  the  amount  of  blood  in  the  brain,  and  to  allay  any  excite- 
ment of  the  nervous  system  that  may  be  present  in  the  sthenic  form  of 
insomnia.  That  the  first-named  of  these  effects  follows  its  use,  I  have 
recently  ascertained  by  experiments  upon  living  animals,  the  details  of 
which  will  be  given  hereafter.  Suffice  it  now  to  say  that  I  have 
administered  it  to  dogs  whose  brains  have  been  exposed  to  view  by 
trephining  the  skull,  and  that  I  have  invariably  found  it  to  lessen  the 
quantity  of  blood  circulating  within  the  cranium,  and  to  produce  a 
shrinking  of  the  brail!    from   this  cause.      Moreover,  we  have  only  to 

observe  its  effects  upon  the  human  subject,  to  be  convinced  that  this 

is  one  of  the  most    important   results  of   its   employment.      The   flushed 

f.ee,  die  throbbing  of  tin  carotids  and  temporals,  the  suffusion  of  the 
eyes,  the  feeling  of  fullness  in  the  head,  all  disappear  as  if  by  magio 
Under  its  use.      It  may  be  given  in  doses  of   from  ten   to   thirty  grains, 

the   latter  quantity  being  seldom  required,  but  may  be  taken  with 

perfect   safety  in  severe  eases." 

Since  then,  experiments  with  the  oephalo-hsemometer  and  ophthal- 

•'  "On  Sleep  and  Insomnia."     New  York  Medical  Journal,  June,  18G5,  p.  203. 
0 


G6  DISEASES   OF   THE   BRAIN. 

moscope  have  abundantly  confirmed  these  views,  and  more  extensive 
experience  in  the  treatment  of  cerebral  congestion  has  placed  the 
matter  beyond  the  possibility  of  a  doubt.  Other  observers  have  also 
confirmed  the  opinions  here  expressed. 

The  prescription  which  I  often  employ  consists  of  bromide  of 
potassium,  3  j  ;  water,  3  iv  ;  of  this  a  teaspoonful  is  taken  three 
times  a  day  in  a  little  water.  Occasionally  the  bromide  is  in- 
creased to  3  iss,  and  sometimes  a  saturated  solution — which  contains 
grs.  xxx  to  3  j — is  used.  I  continue  the  medicine  till  drowsiness,  a 
slight  feeling  of  weakness  in  the  legs,  and  contraction  of  the  blood- 
vessels of  the  retina — detected  by  the  ophthalmoscope — are  pro- 
duced. The  more  prominent  head -symptoms  generally  disappear 
in  four  or  five  days,  and  the  results  above  mentioned  ensue  in  about 
ten  days. 

Latterly  I  have  used  the  bromide  of  sodium  in  corresponding 
doses  instead  of  the  bromide  of  potassium.  It  is  more  pleasant  to 
the  taste,  and  does  not  cause  so  much  constitutional  disturbance  as 
sometimes  follows  the  administration  of  the  bromide  of  potassium  in 
large  doses. 

The  bromide  of  calcium  is  also  well  adapted  to  the  treatment  of 
cases  of  active  cerebral  congestion,  and  has  the  advantage  over  the 
other  bromides  of  acting  more  promptly. 

As  is  well  known,  ergot  possesses  the  property  of  constricting  the 
organic  muscular  fibre.  This  property  has  for  several  years  past  led 
to  its  successful  application  to  the  treatment  of  those  diseases  of  the 
spinal  cord  in  which  it  is  desirable  to  lessen  the  amount  of  blood  in 
its  vessels.  It  is  only  lately,  however,  that  this  agent  has  been  em- 
ployed in  similar  affections  of  the  brain.  From  my  own  experience, 
as  well  as  from  a  consideration  of  the  investigations  of  others,  I  am 
entirely  satisfied  that  ergot  does  contract  the  cerebral  vessels,  and 
hence  that  it  diminishes  the  quantity  of  intracranial  blood.  Among 
the  first,  if  not  the  very  first,  to  call  attention  to  this  property  was 
Dr.  Charles  Aldridge,1  who  noticed  that  after  the  administration  of 
a  full  dose  he  found  it  to  cause  "  contraction  of  the  arteries  of  the 
retina  and  loss  of  the  capillary  tint  of  the  disk."  My  own  observa- 
tions are  entirely  in  accord  with  these  results.  I  have  repeatedly 
found  a  single  dose  of  two  drachms  of  the  fluid  extract  produce  a 
decided  diminution  in  the  calibre  of  the  retinal  arteries,  and  a  marked 
pallor  of  the  disk. 

In  addition,  some  recent  experiments  which  I  have  performed  upon 
dogs,  in  which  the  ergot  was  administered  hypodermically  in  doses  of 
from  one  to  three  drachms  of  the  fluid  extract,  after  the  animals  had 
been  trephined  .and  the  cephalo-hamiometer  inserted  into  the  opening 

1  "West  Riding  Lunatic  Asylum  Reports,"  vol.  i.,  p.  71,  London,  1871;  also  vol. 
Hi.,  p.  230. 


CEREBRAL   CONGESTION.  67 

in  the  skull,  showed  from  the  falling  in  the  tube  that  the  intracranial 
pressure  was  notably  lessened. 

Applying  these  facts  clinically,  it  is  found  that  ergot  is  of  very 
great  value  in  the  treatment  of  active  cerebral  congestion  in  all  its 
forms,  but  especially  in  the  first  or  hyperaemic  stage.  I  am  in  the 
habit  of  giving  drachm-doses  of  the  fluid  extract  three  times  a  day,  in 
combination  with  some  one  of  the  bromides.  An  excellent  formula 
is  sodii  bromidi,  ?  j  ;  ergotae  ext.  fluidi,  §  iv.  M.  ft.  sol.  Dose,  a 
teaspoonful  three  times  a  day. 

Or  the  ergot  may  be  given  alone,  either  in  the  form  of  the  fluid 
extract,  or  of  the  ergotin  of  Beaujon,  which  is  simply  a  solid  extract. 
This  latter  is  made  into  pills  of  from  three  to  five,  or  even  ten  grains 
each,  one  of  which  should  be  administered  three  times  a  day. 

In  the  first  or  hyperaemic  stage,  and  especially  where  the  pain  in 
the  head  has  been  a  prominent  feature,  I  have  frequently  seen  prompt 
relief  of  the  cerebral  distress  from  the  administration  of  ten  or  fifteen 
grains  of  phenacctine. 

At  the  end  of  about  ten  days  it  will  generally  be  found  that  under 
this  treatment  all  symptoms  of  congestion — subjective  and  object- 
ive— have  disappeared,  leaving  a  little  debility  and  mental  depres- 
sion. It  then  becomes  expedient  to  give  tonics  and  restoratives, 
and  those  which  have  a  special  action  on  the  nervous  system  are  to 
be  preferred.  Among  them,  strychnia,  phosphorus,  and  cod-liver  oil 
stand  first. 

Strychnia  may  be  advantageously  administered  in  conjunction 
with  iron  and  quinine  dissolved  in  dilute  phosphoric  acid,  as  in  the 
following  formula  :  Strychnia  sul.,  gr.  j  ;  ferri  pyrophosphatis,  qui- 
nia? sul.,  aa  3  j  ;  acid,  phosp.  dil.,  zingiberis  syrupi,  3a  §  ij-  M-  ft- 
mist.  Dose,  :i  teaspoonful  three  times  a  day  in  a  little  water.  I  pre- 
fer this  extemporaneous  prescription  to  any  of  the  syrups  or  elixirs 
with  like  ingredients;  If  for  any  reason  the  iron  and  quinine  arc 
not  indicated,  the  strychnia  can  be  given  alone  with  the  dilute  phos- 
phoric acid. 

The  eucalyptus,  in  the  form  of  the  fluid  extract,  has  certainly 
in  my  hands  been  productive  of  excellent  results  in  the  treatment 
of  the  hypereemic  stage  of  cerebral  congestion.  This  has  been  espe- 
cially the  case  in  those  instances  in  which  a  malarious  influence  was 
present,  but  it)  which  quinia  could  not  have  been  given  without  run- 
ning the  risk  of  still  further  adding  to  the  quantity  of  intracra- 
nial blood.  An  ounce  of  the  bromide  of  sodium  may  be  dissolved 
in  four  ounces  of  the  fluid  extract,  and  a  teaspoonful  taken  three 
times  a  day. 

Hydrobromic  acid   is  of  no  service  In  the  treatment  of  cerebral 

congestion,  except  U  a  solvent  for  the  sulphate  of  quinia,  the  injurious 
effects  of   which  upon    the  brain   it   modifies  or  prevents.      A    drachm 


68  DISEASES   OF  THE   BRAIN. 

of  Fothergill's  solution  will  counteract  the  congestive  tendency  of 
about  two  grains  of  the  sulphate  of  quinia.  It  may  in  some  cases  be 
advantageously  substituted  for  the  dilute  phosphoric  acid  of  the  for- 
mula just  given. 

Phosphorus  almost  always  acts  well  in  such  cases  as  those  under 
consideration.  It  may  be  given  in  the  form  of  the  phosphorated  oil, 
as  in  the  following  formula:  I£.  Olei  phosphorat.,  §  ss  ;  mucil.  aca- 
cia?, |  j  ;  olei  bergamii,  gtt.  xl.  M.  ft.  emulsion.  Dose,  gtt.  xv.  three 
times  a  day. 

A  very  elegant  preparation  of  phosphorus  is  the  phosphide  of  zinc. 
The  chemical  formula  of  this  substance  is  Zn3  P,  and  consequently  a 
grain  represents  a  little  more  than  one-seventh  of  a  grain  of  phos- 
phorus. The  proper  dose,  therefore,  is  about  the  tenth  of  a  grain.  I 
usually  prescribe  it  in  cerebral  congestion,  according  to  the  following 
prescription  :  I£.  Zinci  phosphidi,  grs.  iij  ;  rosar.  conserv.,  q.  s.  M. 
ft.  in  pil.  no.  xxx.  Dose,  one  three  times  a  day.  Instead  of  the  con- 
serve of  roses,  grs.  x  of  the  extract  of  nux  vomica  may  be  substituted 
if  strychnia  is  not  being  administered  in  some  other  form. 

Another  very  useful  form  for  administering  phosphorus  is  the 
phosphorated  resin,  which  contains  four  per  cent,  of  phosphorus,  thor- 
oughly rubbed  up  with  ninety-six  per  cent,  of  resin.  This  is  made 
into  pills  with  conserve  of  roses,  or  some  other  excipient.  The  dose 
is  about  half  a  grain,  containing  the  one-fiftieth  of  a  grain  of  phos- 
phorus. 

Latterly  I  have  made  much  use  of  arsenious  acid  in  cerebral  con- 
gestion, especially  in  cases  which  have  been  the  result  of  mental  exer- 
tion or  anxiety.  Its  action  is  certainly  preferable  to  that  of  Fowler's 
solution.  It  should  be  given  in  doses  of  about  the  fiftieth  of  a  grain, 
and  after  eating,  and  should  be  continued  for  several  weeks.  Lisle ' 
administers  it  in  the  quantity  of  from  a  fourth  to  the  third  of  a  grain 
daily,  and  there  is  no  doubt  that  it  may  be  given  to  this  extent  with- 
out danger.  I  have  never,  however,  unless  there  was  manifest  insan- 
ity, used  it  in  these  doses. 

In  those  cases  in  which  there  are  dyspeptic  symptoms — and  they 
constitute  the  majority — the  administration  of  pepsin  and  powdered 
charcoal  with  each  meal  will  be  of  decided  benefit ;  and  in  such  cases 
bismuth  is  often  of  great  service. 

Such  is  the  treatment  I  have  found  to  be  most  advantageous  in 
active  cerebral  congestion,  and  I  rarely  have  occasion  to  supplement  it 
with  other  measures,  unless  some  special  indication  is  to  be  fulfilled. 
Thus,  if  the  bowels  are  constipated,  a  mild  purgative  may  be  given,  or 
preferably  an  enema  of  warm  water  or  olive-oil  ;  or,  if  the  urine  is 
scanty  and  high-colored,  saline  diuretics  are  useful. 

1  "  Du  traitement  de  la  congestion  cerebrale  et  de  la  folie  avec  congestion  et  halluci- 
nations par  l'acide  aresenieux."     Paris,  18*71. 


CEREBRAL   CONGESTION.  69 

In  the  passive  form  of  the  disease  it  is  sometimes  advisable  to  give 
stimulants,  which  may  be  done  from  the  first  in  conjunction  with  the 
bromide  of  potassium,  sodium,  or  calcium,  with  ergot.  Alcohol  in 
some  form  is  to  be  preferred  when  it  is  well  borne,  though  carbonate 
of  ammonia  is  sometimes  a  useful  substitute.  In  several  cases  of  pas- 
sive cerebral  congestion  in  old  people,  and  in  one  instance  occurring 
in  the  person  of  a  very  prominent  elderly  gentleman  of  this  city,  I  de- 
rived satisfactory  results  from  sulphuric  ether  inhaled  from  a  handker- 
chief to  the  extent  of  a  teaspoonful  several  times  a  day.  The  pain, 
constriction,  vertigo,  numbness,  wakefulness,  and  inability  to  exert  the 
mind,  were  lessened  with  every  dose,  and  finally  entirely  disappeared. 
Ether  may  likewise  be  given  by  the  stomach — gtt.  xv  several  times 
daily — in  case  the  inhalation  is  contra-indicated  from  any  cause. 

Of  course,  any  influence  capable  of  interfering  with  the  due  return 
of  blood  from  the  head  should  be  counteracted  at  once. 

In  the  two  cases  of  aphasic  cerebral  congestion  of  the  passive  form, 
to  which  reference  has  been  made,  I  derived  the  most  signal  benefit 
from  the  use  of  infusion  of  digitalis  in  tablespoonful-doses  adminis- 
tered every  four  hours. 

Hygienic  treatment  should  in  both  types  of  the  disease  be  persist- 
ently carried  out.  The  food  should  be  nutritious,  digestible,  and  ample, 
though  not  excessive  in  quantity.  Alcohol  and  tobacco,  if  used  habit- 
ually by  the  patient,  should  be  restricted  to  moderate  limits  ;  I  have 
never  seen  the  latter  do  harm  unless  used  to  excess.  Tea  and  coffee 
may  safely  be  left  to  the  patient's  own  inclinations  and  experience. 
I  believe  more  harm  is  done  by  suddenly  breaking  off  a  habit,  even 
though  it  be  somewhat  injurious,  than  by  tolerating  it  within  due 
bounds.  Exercise  in  the  open  air — walking,  horseback-riding,  or  driv- 
ing —is  always  beneficial.  The  same  cannot  be  said  of  gymnastic  con- 
tortions, which,  to  make  them  worse,  are  usually  performed  in  hot 
rooms.  Bathing  daily  and  subsequent  friction  with  a  tape  towel  are 
exceedingly  useful  in  determining  blood  to  the  surface  of  the  body. 
The  Turkish  bath  cannot  be  too  highly  commended,  and  douches  to 
the  nape  of  the  neck,  alternately  hot  and  cold,  in  which  the  water  is 
thrown  with  force  and  from  a  distance  of  ten  or  fifteen  feet,  are  highly 

advantageous. 

But,  above  all,  those  persons  who  have  brought  on  the  disorder  by 
inordinate  mental  exertion  or  anxiety  miisi  consent  to  use  their  brains 
in  a  rational  manner  if  they  wish  to  recover  or  to  avoid  future  attacks. 
They  have  received  a  warning,  and,  if  they  do  not  heed  it,  sooner  or 
later  Other  diseases,  more  difficult  if  not  impossible  of  cure,  will  make 
their  appearance. 

But  it  is  not  always  the  case  that  the  most  positive  advice  on  this 
point  is  followed.  .Men  who  would  readily  see  the  impropriety  of  walk- 
ing, three  or  four  miles  while  suffering  with  an  inflamed  knee-joint, 


70  DISEASES   OF  THE   BRAIN. 

do  not  hesitate  to  exert  a  disordered  brain  to  the  extreme  limit  of  its 
power.  It  is  impossible  that  the  action  of  a  brain  thus  affected  can  be 
such  as  to  evoke  sound  and  healthy  thoughts.  It  is  not  to  be  wondered 
at,  therefore,  that  the  subjects  of  cerebral  congestion  who  insist  upon 
attending  to  their  vocations,  and  on  concocting  schemes  for  obtaining 
wealth  or  fame,  should  perpetrate  acts  which  result  in  the  loss  of  for- 
tune, or  the  acquisition  of  a  reputation  far  different  from  that  sought. 
The  cause  of  cerebral  congestion,  whatever  it  be,  must,  if  prac- 
ticable, be  removed,  aud  it  must  continue  removed. 


CHAPTER   II. 

CEREBRAL     ANEMIA 


In  cerebral  anaemia  the  quantity  of  blood  in  the  brain  is  either 
reduced  below  the  normal  standard,  or  the  quality  of  the  circulating 
fluid  is  impoverished.  The  first-named  condition  is  due  either  to  direct 
loss  of  blood,  to  deficient  action  of  the  heart,  to  impaired  nutrition,  or 
to  some  cause  preventing  the  due  access  of  blood  to  the  brjiin  ;  the 
second  to  disease  of  some  organ  concerned  in  haematosis  or  to  a  gen- 
eral cachexia.  The  two  states  very  often  coexist,  and  they  may  prop- 
erly be  considered  together. 

Symptoms. — In  cerebral  anaemia  suddenly  induced  from  profuse 
haemorrhage,  the  most  prominent  symptom  is  syncope.  Vertigo  is 
generally  an  attendant,  and  there  are  paleness  of  the  features  and 
coldness  of  the  extremities.  The  pulse  is  frequent,  thread-like,  and 
weak.     The  respiration  is  feeble  and  accelerated. 

But,  when  the  accession  is  more  gradual,  headache  is  very  generally 
present.  It  may  be,  and  usually  is,  confined  to  a  limited  portion  of 
the  head,  sometimes  to  a  spot  not  larger  than  the  point  of  the  finger. 
A  feeling  of  constriction,  especially  across  the  brows,  is  complained  of, 
and  the  vertigo,  notably  increased  on  rising  from  the  recumbent  post- 
ure, is  as  troublesome  a  feature  as  in  the  worst  attacks  of  cerebral  con- 
gestion. There  is  ringing  in  the  ears,  and  loud  noises  are  not  only 
painful  but  are  exceedingly  irritating  to  the  nervous  system.  The 
pupils  are  largely  dilated,  and  are  sluggish,  contracting  slowly  and 
but  little  on  exposure  to  a  strong  light.  These  phenomena  may  be 
restricted  to  one  eye,  a  circumstance  which  generally  occasions  needless 
alarm  on  the  part  of  the  patient.  The  retinae  are  extremely  sensitive, 
and  hence  ophthalmoscopic  examination  is  painful.  When  employed, 
the  vessels  at  the  fundus  of  the  eye  are  seen  to  be  small  and  straight, 
and  the  choroid  is  paler  than  is  normal. 

Owing  to  paresis  of  the  ocular  muscles — a  very  common  condition 


CEREBRAL   ANEMIA.  71 

in  cases  of  cerebral  anaemia — the  attempt  to  use  the  eyes,  as,  for  in- 
stance, in  reading,  produces  pain  in  them  and  in  the  head.  In  many- 
cases  the  effort  of  three  or  four  minutes  causes  very  great  uneasiness. 

The  complexion  is  pale,  the  lips  almost  colorless,  or  else  redder  than 
in  health.     The  skin  is  cold  and  clammy. 

Nausea  and  vomiting  are  present  in  extreme  cases,  and  convulsions 
of  an  epileptic  character  may  occur.  In  the  rapidly-developed  form  of 
the  disease,  caused  by  sudden  and  great  loss  of  blood,  they  are  always 
present,  and  in  the  milder  and  more  gradual  variety  they  are  occasion- 
ally seen.  Feebleness  of  muscular  power  is  always  met  with,  and  there 
may  be  general  or  partial  paralysis,  with  the  usual  derangements  of 
sensibility  indicative  of  anaesthesia,  such  as  coldness,  formication,  and 
"pins  and  needles." 

The  mind,  of  course,  participates  in  the  general  disorder.  In  ex- 
treme cases,  due  to  active  ha3morrhage,  the  patient  is  completely  insen- 
sible. In  less  severe  forms  there  may  be  all  the  gradations  from  low 
delirium  to  great  mental  irritability,  or  a  condition  of  intellectual  lassi- 
tude approaching  dementia. 

Hallucinations  and  illusions  are  common  in  the  slowly-developed 
forms  of  cerebral  anaemia,  and  may  affect  any  one  or  all  of  the  senses. 
Those  of  sight  and  hearing  are,  however,  more  prominent.  In  the  case 
of  a  young  lady  under  my  care,  and  whose  only  marked  disorder  was 
that  under  consideration,  the  hallucination  that  she  saw  a  black  man 
was  almost  constantly  present.  At  times  she  conversed  with  this  im- 
aginary being,  told  him  not  to  trouble  her,  that  she  no  longer  feared 
him,  etc.  She  believed  firmly  in  his  presence,  and  hence  had  a  delu- 
sion. 

In  all  cases  of  cerebral  anamiia  there  is  more  or  less  drowsiness, 
from  the  profound  syncope  of  the  rapid  form  to  the  rather  agreeable 
languor  present  in  slight  cases.  In  instances  of  medium  severity,  the 
patient  readily  falls  asleep  in  the  siding  posture  ;  but  recumbency  in- 
duces wakefulness,  from  the  fact  that  the  quantity  of  blood  in  the 

brain  is  thereby  suddenly  Increased   above  the  habitual  standard,  and 

a  state  of  comparative  hyperemia  is  thus  induoed.     1  have,  in  another 

place,1  called  attention  to  this  form  of  insomnia,  and  adduced  several 
oases  in  illustration. 

Examination  of   the  heart   by  auscultation  reveals  the  existence  of 

bellows-murmurs,  both  systolic  and  diastolic.     They  are  heard  more 

loudly  at  the  base  of  the  heart.  There  are  also  very  generally  venous 
murmurs,  which  are  heard  mosl  distinctly  in  the  jugular  veins,  espe- 
cially when  the  head  is  turned  toward  the  opposite  side.  Arterial 
murmurs  may  also  occasionally  be  perceived. 

These  sounds  are  sometimes  heard  by  the  patient,  and  are  then  ex- 
ceedingly annoying.      I   have   had    under  m\  charge  patients  goffering 
1  "Bleep  and  Its  Derangements." 


72  DISEASES   OF   THE   BRAIN. 

from  cerebral  anaemia,  who  constantly  heard  a  sound  originating  ap- 
parently in  the  head,  and  which,  as  they  described  it,  resembled  that 
caused  by  a  large  shell  placed  in  the  ear.  That  these  murmurs  are 
anaemic,  is  shown  by  the  fact  that  they  disappear  under  appropriate 
treatment. 

Cerebral  ana?mia  may  be  of  such  intensity  and  be  so  suddenly  de- 
veloped as  to  cause  almost  instant  death.  Many  cases  are  on  record 
of  patients  having  died  with  symptoms  of  apoplexy,  and  in  whom  post- 
mortem examination  has  shown  the  blood-vessels  of  the  brain  to  be 
empty,  and  the  brain  itself  pale  and  exsanguined. 

Paralysis  of  various  forms  may  likewise  result  from  this  condition. 
Sometimes  there  is  hemiplegia,  at  others  paraplegia ;  again  a  single 
muscle  or  a  group  of  muscles  may  be  affected,  and  it  may  even  happen 
that  a  general  state  of  paralysis  may  exist.  I  have  frequently  seen  a 
single  muscle  of  the  eyeball  alone  involved,  and  upon  one  occasion 
witnessed  the  loss  of  muscular  power  confined  to  one  side  of  the  face 
in  the  person  of  a  lady  whose  brain  was  evidently  very  anaemic. 

Gintrac  '  cites  the  following  interesting  cases  communicated  to  him 
by  Dr.  Hirigoyen  : 

"  A  young  girl  twenty  years  old,  affected  with  amenorrhea,  con- 
sulted a  midwife,  who  bled  her,  attributing  her  trouble  to  cerebral 
plethora.  She  had  hardly  lost  two  hundred  grammes  of  blood  when 
hemiplegia  supervened.  Iron  and  tonics  entirely  dissipated  this  con- 
dition. 

"A  young  woman,  twenty-five  years  old,  was  subject  to  a  severe 
epigastric  pain,  that  had  been  several  times  relieved  by  bloodletting. 
She  was  thin,  pale,  and  nervous.  Nevertheless,  a  vein  was  again 
opened,  but  only  about  one  hundred  and  fifty  grammes  of  blood  were 
taken.  Notwithstanding  this  prudence,  a  syncope  ensued  while  the 
arm  was  being  tied  up,  and  there  were  some  convulsive  movements. 
After  two  or  three  minutes  the  patient  recovered  her  senses,  but  was 
found  to  be  entirely  hemiplegic  on  the  left  side,  and  to  have  some 
difficulty  of  speech.  Recourse  was  had  to  Hoffman's  anodyne,  vale- 
rian, and  appropriate  food,  and  at  the  end  of  thirty-six  hours  she  was 
relieved." 

A  form  of  cerebral  ana?mia  met  with  in  young  children  is  of  great 
importance,  from  the  fact  of  its  liability  to  be  confounded  with  arf- 
other  far  more  dangerous  affection,  almost  its  opposite.  This  was  first 
clearly  described  by  Dr.  Gooeh,2  although  previously  noticed  by  other 
observers.  In  children  suffering  from  this  affection,  the  symptoms,  so 
far  as  they  are  noticeable,  are  similar  to  those  present  in  the  anaemia 

1  "  Traite  theorique  et  pratique  dcs  maladies  de  l'appareil  ncrvcux."  Tome  premier, 
Paris,  1869,  p.  548. 

8  "  On  Some  of  the  most  Important  Diseases  peculiar  to  Women ;  with  Other  Papers." 
New  Sydenham  Society  Publication.     London,  1859,  p.  179. 


CEREBRAL   AX.EMIA.  73 

of  adults.  The  drowsiness  is  well  marked,  the  head  is  cool,  the  pulse 
is  small  and  weak,  the  features  are  pinched,  the  pupils  large  and  in- 
sensible to  light,  and  the  fontanelle,  if  still  open,  has  the  scalp  cover- 
ing it  depressed.  After  death,  the  vessels  of  the  brain  are  found  to  be 
almost  empty,  and  the  ventricles  distended  with  fluid.  From  its  re- 
semblance in  some  respects  to  hydrocephalus  or  tubercular  meningitis, 
this  affection  was  called  by  Dr.  Marshall  Hall  hydrocephaloid.  The 
distinction,  however,  is  so  well  defined,  that  none  but  the  most  igno- 
rant or  superficial  observers  would  fail  to  recognize  it. 

In  some  cases  of  cerebral  anaemia  a  tendency  to  melancholia  exists, 
and  positive  insanity  may  eventually  result.  In  most  instances  of  the 
disease  there  is  mental  depression,  with  a  strong  predisposition  to  the 
production  of  hypochondria. 

Causes. — Haemorrhage  or  other  exhausting  discharge  ranks  first 
among  the  causes  of  cerebral  anaemia.  I  have  known  several  severe 
cases  induced  by  epistaxis,  and  one  by  the  continued  loss  of  blood 
from  leech-bites.  Haemorrhoidal  bleeding  has  also  caused  it  in  my 
experience.  No  influence  of  the  kind  is,  however,  more  common  than 
uterine  bleeding,  such  as  occurs  before,  during,  or  after  labor,  from 
miscarriages  and  abortions,  especially  if  they  are  frequently  repeated, 
and  from  excessive  menstrual  discharge. 

Chronic  dysentery  and  diarrhoea,  malarial  and  other  fevers,  the 
rheumatic,  strumous,  and  cancerous  diatheses,  diseases  of  the  bones 
and  joints,  and  long-continued  purulent  discharges,  are  likewise  causes 
of  cerebral  anaemia. 

I  have  several  times  seen  the  affection  apparently  caused  by  con- 
gestion of  internal  organs.  Niemeyer,  referring  to  this  possibility, 
cites  the  fact  that  it  may  follow  the  use  of  Jounod's  boot.  At  the 
pn  sent  time,  when  this  appliance  is  variously  modified  and  extended 
beyond  it>  legitimate  use  by  itinerant  quacks,  it  is  well  to  call  special 
attention  to  this  liability.  Several  cases  in  point  have  come  under  my 
observation,  and  in  one,  a  young  lady  suffering  from  epilepsy  with 
oerebral  anaemia,  whom  I  saw  in  consultation  with  my  friend  Dr.  J. 
M;uion  Sims,  severe  paroxysms  were  induced  by  each  application  of 
the  "  exhauster."  In  this  case  the  operator  placed  the  whole  body, 
with  the  exception  of  the  head,  in  a  vacuum.  In  another  instance, 
exhaustion  from  the  leg  alone  cause. 1  syncope  every  time  the  operation 

was  performed. 

Pressure  upon  or  obliteration  of  the  arteries  rapplying  the  brain  is 

another  cause,  and  may  he  produced    l>y  ligation   of   the  arteries  or  l.y 

tumors  of  various  kinds.     Feebleness  of  the  heart's  action,  such  as 
results  from  fatty  degeneration,  may  also  occasion  cerebral  ansamia. 
As  we  have  seen,  excessive  mental  exertion  is  a  common  cause  of 

Cerebral    congestion.      Strange    as    il    may    appear,  I    have    had    several 

cases'  of  cerebral  ansamia  under  my  care,  in  which  the  disease  was 


74  DISEASES   OF   THE   BRAIN. 

clearly  the  result  of  a  like  cause,  and  these  were  instances  in  which 
the  brain  had  been  overtasked  to  an  extreme  degree.  A  little  reflec- 
tion will,  I  think,  show  that  such  cases  are  strictly  in  accordance  with 
what  takes  place  in  other  parts  of  the  body.  Thus,  we  see  the  moder- 
ate use  of  a  muscle  or  set  of  muscles  increase  their  size  and  strength. 
Inordinate  exercise  induces  hypertrophy,  but,  if  the  power  of  the 
muscles  be  still  more  severely  tried,  atrophy  results.  One  of  the  worst 
cases  of  progressive  muscular  atrophy  I  ever  saw  occurred  in  the  per- 
son of  a  ballet-dancer,  whose  gastrocnemii  muscles  were  the  apparent 
starting-points  of  the  disease.  Excessive  cerebral  action  produces 
exhaustion,  and  exhaustion  causes  anaemia,  as  surely  as  anaemia  causes 
exhaustion. 

The  action  of  mental  emotions  is  more  obvious.  We  know  that 
some  emotions  increase  the  amount  of  blood  in  the  brain.  Others  di- 
minish it,  and  sometimes  with  such  suddenness  as  to  cause  syncope. 
Fear  is  one  of  these,  and  we  have  all  seen  the  face  become  paler  under 
its  influence. 

Certain  medicines  are  causes  of  cerebral  anaemia,  both  by  their 
action  on  the  vaso-motor  nerves  and  in  diminishing  the  power  of  the 
heart.  Tobacco,  tartarized  antimony,  calomel,  oxide  of  zinc,  and  the 
bromides  of  potassium,  sodium,  calcium,  and  lithium,  are  among  the 
chief  of  these.  I  was  the  first  to  point  out  this  influence  of  the  bro- 
mides, and,  in  a  recently-published  memoir,1  have  given  several  cases 
in  illustration  of  its  action.  The  drowsiness,  vertigo,  nausea,  faint- 
ing, weakness  of  the  muscular  system,  numbness,  failure  of  memory, 
mental  aberration,  pallor  of  the  countenance,  and  anaemia  of  the  reti- 
na, all  go  to  show  that  the  quantity  of  blood  in  the  brain  is  dimin- 
ished. Recent  investigations  not  yet  published  have  convinced  me 
that  the  oxide  of  zinc  acts  in  a  similar  manner. 

Insufficient  nutrition,  either  from  deficient  or  improper  food  or  dis- 
ease of  the  digestive  or  assimilative  organs,  is  a  very  common  cause. 
Through  its  influence  not  only  is  the  absolute  amount  of  blood  less- 
ened, but  its  quality  is  deteriorated.  The  quantity  sent  to  the  brain 
is  hence  diminished,  and  that  which  is  supplied  is  lacking  in  its  proper 
proportion  of  red  corpuscles.  Many  of  the  cases  of  cerebral  anaemia 
occurring  in  large  cities  originate  from  such  influences,  and  likewise 
from  the  vitiated  air  of  narrow  and  crowded  streets,  from  cold,  and 
from  deprivation  of  light. 

Sudden  cerebral  anaemia  may  be  produced  by  the  ahock  caused  by 
physical  injuries,  or  even  slight  surgical  operations  unattended  by 

1  "  On  Some  of  the  Effects  of  the  Bromide  of  Potassium  when  administered  in  Large 
Doses."  Quarterly  Journal  of  Psychological  Medicine,  January,  1569,  p  46.  In  this 
paper  I  stated  that  one  of  the  most  constant  phenomena  was  contraction  of  the  pupils. 
Very  greatly  increased  experience  has  convinced  me  that  this  is  an  occasional  circum- 
stance, which  occurs  during  the  early  period  of  administration  only. 


CEREBRAL   ANEMIA.  75 

effusion  of  blood.     Thus  I  have  several  times  seen  it  follow  immedi- 
ately on  the  passage  of  a  urethral  catheter  or  bougie  for  the  first  time. 

The  passage  of  a  galvanic  current  of  too  great  a  degree  of  intensity 
through  the  brain  may  be  productive  of  alarming  symptoms  due  to  sud- 
denly-induced cerebral  anaemia.  Upon  one  occasion  I  passed  a  current 
from  ten  cells  transversely  through  the  brain  of  a  gentleman — the  poles 
being  on  the  mastoid  processes — with  the  effect  of  causing  syncope, 
extreme  nausea,  a  cold  perspiration  on  the  head  and  face,  and  such 
feeble  action  of  the  heart  as  to  cause  me  to  apprehend  the  most  serious 
results.  Placing  the  head  in  the  dependent  position,  and  causing  him 
to  inhale  the  nitrite  of  amyl,  soon  restored  him  to  consciousness,  and 
dissipated  the  other  symptoms. 

In  another,  somewhat  similar  though  not  so  violent  symptoms  were 
induced  by  the  passage  of  a  current  from  only  six  cells.  Cologne  to 
the  nostrils,  and  a  draught  of  strong  whiskey,  afforded  prompt  relief. 

These  cases,  as  well  as  others  within  my  knowledge  or  experience, 
show  how  sensitive  some  persons  are  to  the  primary  current,  and  indi- 
cate the  care  necessary  in  the  use  of  this  powerful  agent. 

An  instance  of  extreme  cerebral  anaemia,  produced  by  excitation  of 
the  pneumograstic  nerve  by  a  galvanic  current  of  too  great  a  degree  of 
intensity,  will  presently  be  cited. 

Diagnosis. — The  principal  affection  with  which  cerebral  anaemia  is 
liable  to  be  confounded,  is  cerebral  congestion.  Indeed,  there  is  no 
other  which  can  be  mistaken  for  it,  if  even  ordinary  perception  and 
judgment  be  exercised. 

From  this  it  may  be  diagnosticated  by  the  history  of  the  case,  and 
a  careful  inquiry  into  the  etiology,  by  the  facts  that  drowsiness,  not 
wakefulness,  is  a  prominent  symptom  ;  that  the  pupils  are  dilated  in- 
stead of  being  contracted  ;  that  the  pain  is  more  apt  to  be  fixed  in  a 
limited  part  of  the  head  instead  of  being  general  ;  that  it  and  the  ver- 
tigo an-  increased  by  the  assumption  of  the  erect  position,  and  dimin- 
ished by  lying  down  ;  that  the  ophthalmoscope  shows  retinal  ansemia  ; 
that  the  face  is  pale  and  the  skin  cold  ;  that  the  pulse  is  weak  and  fre- 
quent ;  and  thai  bellows-murmurs  are  heard  at  the  base  of  the  heart 
and  in  the  veins  of  the  neck.  The  effect  of  stimulants  and  tonics  in 
mitigating  these  symptoms,  and  the  fad  thai  they  are  increased  by  ex- 
ertion and  debilitating  influences,  are  also  important  points  to  be  con- 
sidered in  forming  a  diagnosis.  Attentive  consideration  of  these  dif- 
ferential phenomena  will  prevent  a  mistake  which  may  be  fatal  to  the 
pal  ient. 

Prognosis.—' The  prospect  of  recovery  in  cases  of  cerebral  ameinia 
depends  mainly  upon  the  removal  of  the  cause,  and  the  adoption  of* 
suitable  treatment.      In  those  cases  which  are  the  result  of  sudden  and 

profuse  Loss  of  blood,  the  prognosis  is  grave,  and  this  is  especially  so  if 

the   patient    i>   pulseless   and    OOnvulsionS   have   occurred.      In   such    in- 


76  •  DISEASES   OF   THE   BRAIN. 

stances,  even  though  the  haemorrhage  has  heen  arrested,  it  may  he 
impossible  to  save  the  patient. 

In  the  gradually-developed  form  the  prognosis  is  generally  f avorahle. 

Morbid  Anatomy. — The  vessels  of  the  brain  and  its  membranes  are 
observed  upon  post-mortem  examination  to  contain  less  than  the  normal 
amount  of  blood.  The  tissue  of  the  brain  is  pale,  and  section  shows  a 
diminished  number  of  the  red  points  in  the  white  substance.  Some- 
times there  is  an  increased  amount  of  serous  effusion  in  the  sub- 
arachnoid space,  but  the  ventricles  are  generally  empty. 

Pathology. — The  questions  to  be  discussed  under  this  head  are 
similar  to  those  connected  with  the  same  point  in  cerebral  congestion. 
That  the  quantity  of  blood  within  the  cranium  can  be  diminished  as 
well  as  increased  admits  of  no  doubt,  and  the  fact  that  the  symptoms 
grouped  together  as  indicating  the  existence  of  cerebral  anaemia  are 
really  the  result  of  deficient  blood-supply  to  the  brain  is  equally  certain. 
The  experiments  of  Kussmaul  and  Tenner/  as  well  as  those  of  other 
physiologists,  are  perfectly  convincing. 

To  observe  in  man  the  effects  of  even  temporarily  cutting  off  the 
supply  of  blood  to  the  brain,  it  is  only  necessary  to  compress  the 
carotid  arteries  for  a  few  moments.  I  have  repeatedly  done  this  in  rab- 
bits to  the  extent  of  producing  insensibility  and  convulsions.  Jacobi a 
relates  the  following  symptoms  as  generally  observed  in  the  human 
subject  :  Dimness  of  sight,  dizziness,  stupor,  weakness  in  the  legs,  stag- 
gering, swooning,  loss  of  consciousness,  and  sudden  apoplectic  falling 
down. 

Dr.  Alexander  Fleming8  tried  the  effect  of  compressing  the  carotid 
arteries.  "  There  is  felt  a  sort  of  humming  in  the  ears,  a  sense  of  tingling 
steals  over  the  body,  and  in  a  few  seconds  complete  unconsciousness 
and  insensibility  supervene,  and  continue  as  long  as  the  pressure  is 
maintained.  I  have  recently  performed  this  experiment  several  times, 
with  the  effect  of  producing  similar  phenomena,  together  with  pallor 
of  the  countenance,  dilatation  of  the  pupils,  and  temporary  headache." 

In  many  cases  of  cerebral  anaemia,  the  cause,  as  we  have  seen, 
resides  in  the  blood-producing  functions,  and  is  such  as  to  cause  the 
formation  of  blood  which  does  not  contain  its  due  supply  of  red  cor- 
puscles. Here,  although  there  may  be  no  diminution  in  the  actual 
volume  of  this  fluid  circulating  in  the  cerebral  vessels,  the  effect  is  the 
same  so  far  as  the  nutrition  of  the  organ  is  concerned,  and  hence  the 
symptoms  of  anaemia  are  slowly  evolved. 

1  "  Untersuchungen  iiber  Ursprung  und  "Wesen  der  fallsuchtartigen  Zuckungcn." 
Frankfurt,  1857.  Also,  "On  the  Nature  and  Origin  of  Epileptiform  Convulsions,  caused 
by  Profuse  Bleeding,"  etc.     New  Sydenham  Society  Translation,  1859. 

4  Quoted  by  Kussmaul  and  Tenner. 

z  British  and  Foreign  Medico- Chirurgical  Revicio,  April,  1855,  p.  529,  in  a  paper  en- 
titled "  Note  on  the  Induction  of  Sleep  and  Anaesthesia  by  Compression  of  the  Carotids." 


CEREBRAL   ANAEMIA.  77 

Again,  it  cannot  be  doubted  that  spasm  of  the  blood-vessels  pro- 
duced through  the  sympathetic  and  vaso-motor  nerves  explains  the 
origin  and  continuance  of  many  cases  of  cerebral  anaemia.  It  is  in  this 
way  that  mental  emotions  act,  and  sometimes  with  such  rapidity  as  to 
cause  instant  death.  This  spasm  may  be  kept  up  for  a  very  consid- 
erable period,  with  the  effect  of  developing  the  ordinary  symptoms  of 
cerebral  anaemia,  even  after  the  emotion  which  originated  it  has  long 
since  disappeared. 

Treatment. — The  first  indication  to  be  fulfilled  in  the  treatment  of 
cerebral  anaemia  is  to  get  rid  of  the  cause.  It  often  happens  that  this 
is  still  in  active  operation  when  patients  come  under  our  care,  and 
there  is  no  hope  of  permanent  success  till  it  is  removed.  Thus,  if 
there  is  haemorrhage  from  a  divided  vessel,  from  the  uterus,  the  bow- 
els, the  lungs,  or  other  part  of  the  body,  it  must  be  arrested  ;  if  there 
is  exhausting  discharge  from  the  air-passages,  the  intestines,  or  the 
genital  organs,  it  must  be  stopped  ;  if  the  digestive  or  assimilative 
organs  do  not  perfectly  perform  their  offices,  they  must  be  put  in 
good  condition  ;  if  a  tumor  or  other  obstruction  to  the  due  course  of 
the  blood  to  the  brain  exist,  it  must  be  removed  ;  and  if  the  hygienic 
conditions  surrounding  the  patient  be  bad,  or  the  food  inadequate  in 
quantity  or  quality,  they  must  be  improved. 

No  medicine  exercises  so  powerful  an  effect  in  cerebral  anaemia  as 
alcohol  in  some  form  or  other.  Perhaps,  all  things  considered,  the 
spirituous  liquors,  such  as  whiskey,  brandy,  and  rum,  are  more  gen- 
erally applicable  ;  for  the  influence  is  more  rapidly  felt,  and  there  is 
not  the  same  risk  of  exciting  or  aggravating  gastric  disorder  as  when 
vinous  or  malt  liquors  are  used.  The  quantity  must  be  regulated  ac- 
cording to  the  circumstances  of  each  case,  and  should  always  be  large 
enough  to  materially  increase  the  force  of  the  heart. 

But  if  this  were  the  only  effect  of  alcohol,  its  benefits  in  cerebral 
ansemia  would  be  bul  temporary,  and  would  certainly  be  followed  by 
a  period  "f  depression.  Aside,  however,  from  its  stimulating  action 
on  the  heart,  its  tendency  is  to  improve  the  appetite  and  digestive 
power,  and  to  relax  any  spasm  of  the  blood-vessels  that  may  be 
present. 

Occasionally  it  happens  that  alcohol  is  badly  borne  by  amende  pa- 
tients. The  brain  has  for  so  long  a  time  been  deprived  of  :i  <\uv 
amount  of  its  natural  stimulus — blood — that  time  is  required  to  enable 
it  to  tolerate, and  be  improved  in  tone  by, the  increased  supply.    Tims 

the  physician  will   find    that   in  some   oases    the   patients  will  he   appar- 
ently rendered  worse  by  the  remedy  which  of  all  others  is  calculated 

to  do  them  most  good.      The   headache   and  vertigo   are   increased,  the 

general  feeling  of  debility  and  ,, minis,   greatly  augmented,  and  the 

complaint  is  made  that  the  liquor  has  u  gone  to  the  head." 

Now,  it  must  be  recollected  that  the  brains  of  amende  persons  are 


78  DISEASES   OF  THE  BRAIN. 

in  very  much  the  same  condition  as  the  eyes  of  those  who  have  for  a 
long  time  been  shut  out  from  their  natural  stimulus — light.  When 
the  full  blaze  of  clay  is  allowed  to  fall  upon  their  retina?,  pain  is  pro- 
duced, the  pupils  are  contracted,  and  the'lids  close  involuntarily.  The 
light  must  be  admitted  in  a  diffused  form,  and  gradually,  till  the  eye 
becomes  accustomed  to  the  excitation.  So  it  is  with  the  use  of  alcohol 
in  some  cases  of  cerebral  anremia.  The  quantity  must  be  small  at 
first,  and  it  must  be  administered  in  a  highly-diluted  form,  though  it 
may  be  frequently  repeated.  Cases  in  which  this  intolerance  of  stimu- 
lants is  exhibited  are  almost  invariably  of  long  duration,  and  are  as 
those  in  which  from  a  like  cause  wakefulness  is  produced  by  the  re- 
cumbent posture. 

The  carbonate  of  ammonia,  or  the  aromatic  spirits  of  ammonia, 
may  be  given  if  there  are  any  special  reasons  why  alcohol  should  not 
be  used,  but  they  are  not  to  be  compared  to  it  in  efficacy. 

In  very  extreme  cases  ether  is  preferable  for  the  time  being  to  any 
of  the  foregoing  remedies,  on  account  of  its  diffusive  nature  ;  and 
transfusion  may  be  necessary  to  save  life. 

My  recent  experience  disposes  me  to  put  a  very  high  value  upon 
the  nitrite  of  amyl  in  the  treatment  of  cerebral  ana?mia.  Aldridge  * 
has  shown  that  it  causes,  when  inhaled,  dilatation  of  the  retinal  arte- 
ries ;  and  the  other  phenomena  of  its  action,  the  feeling  of  fullness  in 
the  head  and  the  redness  of  the  face  and  scalp,  unite  to  prove  that  it 
exercises  a  like  effect  over  the  vessels  of  the  brain. 

In  the  cerebral  anremia  of  weak  and  chlorotic  girls  it  is  especially 
valuable,  although  there  is  no  form  of  the  affection,  whether  transitory 
or  permanent,  in  which  it  will  not  prove  beneficial.  Even  a  single 
dose  of  four  drops  inhaled  from  a  handkerchief  has  repeatedly  in  my 
hands  relieved  ansemic  headaches,  and  effectually  dissipated  syncope, 
the  result  of  a  feeble  action  of  the  heart.  Upon  one  occasion  I  had, 
rather  imprudently,  perhaps,  acted  in  a  case  of  goitrous  exophthalmia 
upon  the  pneumogastric  nerve  with  a  galvanic  current  of  too  great  a 
degree  of  intensity.  The  heart  was  rendered  exceedingly  weak  and 
irregular  in  its  pulsations.  The  patient,  a  lady,  became  insensible 
from  syncope,  and  was  unable  to  swallow  the  brandy  I  held  to  her 
lips.  I  poured  a  few  drops  of  the  nitrite  of  amyl  on  a  handkerchief 
and  held  it  to  her  mouth.  Immediately  the  action  of  the  heart  be- 
came stronger,  the  color  began  to  return  to  the  face,  and  conscious- 
ness was  at  once  regained. 

In  chronic  cerebral  ansemia,  the  nitrite  of  amyl  should  be  admin- 
istered in  doses,  by  inhalation,  of  from  four  to  eight  drops  three  times 
a  day.  This  course  may  be  continued  as  long  as  may  be  necessary, 
without  the  slightest  deleterious  result.  I  have  repeatedly  persevered 
with  it  for  a  year,  in  cases  of  epilepsy,  with  the  happiest  effect.  It 
1  "  West  Riding  Lunatic  Asylum  Reports,"  vol.  i.,  1871,  p.  11. 


CEREBRAL   ANAEMIA.  79 

has  never  in  my  experience  been  requisite  to  use  it  longer  than  a  few- 
weeks  in  cases  of  cerebral  anaemia. 

Among  the  more  efficacious  medicines  to  be  employed  in  cerebral 
anaemia,  opium  and  its  preparations  occupy  a  high  place.  Several 
years  since  I  pointed  out '  the  effects  of  opium  upon  the  cerebral  circu- 
lation, and,  as  the  result  of  many  experiments,  urged  that  this  drug 
should  be  used  in  brain-diseases  with  due  discrimination.  It  was  then 
shown  that  small  doses  of  opium  increase  the  supply  of  arterial  blood 
to  the  brain.  In  the  treatment  of  cerebral  anaemia  I  have  derived  the 
most  decided  benefit  from  doses  of  opium  not  exceeding  half  a  grain, 
and  preferably  a  quarter  of  a  grain,  given  three  or  four  times  a  day, 
and  continued  for  several  weeks.  An  equivalent  or  even  smaller  pro- 
portional dose  of  morphia  may  be  exhibited,  instead  of  the  entire  drug. 

It  may  seem  strange,  with  the  cases  I  have  given,  and  with  the 
knowledge,  from  experiment  and  ophthalmoscopic  examination,  rela- 
tive to  the  power  of  the  primary  galvanic  current  applied  to  the  brain 
or  sympathetic  nerve  to  contract  the  cerebral  blood-vessels,  that  I 
should  recommend  the  use  of  galvanism  in  cases  of  cerebral  anaemia. 
Clinical  experience,  however,  shows  that  it  is  decidedly  beneficial,  pro- 
vided the  tension  be  very  low.  I  am  satisfied  that  not  more  than  two 
or  three  cells  should  be  brought  into  action  in  such  cases,  and  that  the 
current  should  only  be  passed  for  a  few  seconds  at  a  time. 

As  adjuncts  to  these  means,  the  bitter  tonics,  such  as  quinine, 
gentian,  columbo,  and  quassia,  are  useful.  Iron  is  almost  always  re- 
quired, though  there  are  patients  who  do  not  tolerate  it.  In  such  cases 
manganese  may  be  substituted  with  advantage.  I  have  frequently  used 
the  sulphate,  in  doses  of  five  grains,  with  excellent  results.  When  iron 
is  borne,  I  know  of  no  better  combination  than  that  given  on  page  68. 
Cod-liver  oil  is  also  a  valuable  agent  in  the  disease  under  consideration. 

It  must  not  be  forgotten  that  food  is  the  most  important  factor  in 
relieving  chronic  cerebral  ansemia.  The  main  permanent  influence  of 
stimulants  and  tonics  18  exerted  upon  the  appetite  ami  digestion,  and 
the  blood  and  tissue  forming  funet ions,  mainly  as  an  excitant.  The 
real  Strength  must  come  from  the  food.  This  should,  therefore,  he  of 
good  quality  ;  animal  food,  such  as  milk,  eggs,  and  meats  of  various 
kinds,  forming  its  chief  portion. 

The  influence  of  position  should  always  be  taken  advantage  of  to 

facilitate  the  flow  of  blood  to  the  head,  and  the  erect  posture  avoided 
iV  as  possible,  especially  during  the  early  stages  of  the  treatment. 
Thus  (he  patient  should  he  encouraged  to  pass  a  good  portion  of  the 
day  in  a  reeiimhent  position,  ami  should  he  instructed  to  assume  it  at 
once  on  the  occurrence  of  any  aggravation  of  the  symptoms. 

The  opposite  course  i^  fraughl  w  it h  danger.     Physicians  are  often 

anxious  that  their  patients  should  take  physical  exercise,  hut  it  must  be 
1  "Sleep  and  its  Derangements."    Philadelphia,  18G9,  p.  25. 


80  DISEASES   OF   THE   BRAIN. 

remembered  that  those  who  suffer  from  cerebral  anaemia  have  very  little 
vital  energy,  and  a  diminished  amount  of  blood  is  circulating  through 
the  organ  from  which  the  greater  part  of  their  nervous  power  comes. 
Muscular  exercise  lessens  the  energy,  and  still  further  reduces  the 
quantity  of  blood  in  the  brain,  for  the  muscles  require  an  increased 
supply  while  in  a  state  of  activity.  To  be  sure,  after  the  strength  of 
the  system  is  in  a  measure  improved,  the  blood  increased  in  quantity 
and  quality,  and  the  brain  supplied  with  something  like  its  proper  pro- 
portion, moderate  physical  exercise  is  of  the  greatest  service. 

I  have  several  times  witnessed  severe  consequences  from  the  as- 
sumption of  the  sitting  or  erect  position  too  soon  after  a  profuse 
haemorrhage,  and  in  one  case  death  resulted. 

As  regards  mental  labor,  there  is  not  much  need  of  caution,  for  the 
reason  that  it  is  impossible  for  the  patient  to  undertake  it  to  any  dan- 
gerous extent.  But,  as  he  improves  in  strength,  the  desire  to  make  use 
of  his  increased  power  may  be  manifested.  It  is,  therefore,  well  at  this 
time  to  prohibit  any  such  exertion  as  will  probably  be  followed  by 
marked  depression.  Moderate  mental  exercise  is,  however,  far  from  be- 
ing prejudicial,  for  it  tends  to  increase  the  amount  of  blood  in  the  brain. 

Emotional  disturbance  should  also,  as  a  rule,  be  avoided,  although 
at  times  it  may  be  productive  of  great  benefit,  especially  if  it  be  pos- 
sible to  bring  into  action  an  emotion  contrary  to  that  which  may  have 
produced  the  disease.  Thus  a  lady  became  subject  to  cerebral  anaemia, 
directly  the  result  of  painful  emotions  due  to  domestic  trouble.  The 
cause  was  very  suddenly  removed,  or  rather  the  knowledge  of  its  re- 
moval was  suddenly  communicated  to  her.  The  reaction  was  very  great; 
she  was  thrown  into  a  state  of  joyous  excitement,  attended  with  consid- 
erable febrile  disturbance,  and  I  was  apprehensive  for  a  time  that  her 
mind  might  become  permanently  deranged,  for  there  were  hallucinations 
and  delusions  of  various  kinds,  and  many  symptoms  of  cerebral  conges- 
tion. But  in  the  course  of  a  few  days,  during  which  she  was  kept  in  entire 
seclusion,  and  as  far  as  possible  from  all  mental  and  physical  agitation, 
she  entirely  recovered  both  from  the  secondary  and  primary  disorders. 


CHAPTER  III. 

CEREBRAL     HEMORRHAGE. 

Under  the  designation  of  cerebral  haemorrhage  I  propose  to  con- 
sider that  disease  which  is  often  known  as  apoplexy,  hemiplegia,  or  a 
paralytic  stroke,  and  which  is  due  to  the  rupture  of  a  blood-vessel,  and 
the  consequent  extravasation  of  blood  either  into  the  substance  of  the 
brain  or  into  its  ventricles. 


CEREBRAL   HEMORRHAGE.  81 

Two  forms  of  the  affection,  differing1  essentially  only  in  the  extent 
or  seat  of  the  lesion,  but  presenting  different  symptoms,  are  to  be  dis- 
tinguished ;  these  are  the  apoplectic  and  paralytic.  In  the  first  there 
is  loss  of  consciousness  ;  in  the  second  the  mind,  though  perhaps  im- 
paired, is  not  suspended  in  its  action. 

Symptoms. — Before  the  full  development  of  the  attack  there  often 
is,  for  several  days,  a  group  of  symptoms  present  which  indicate  cere- 
bral disorder.  These  are  very  much  of  the  same  character  as  those 
denoting  the  first  stage  of  cerebral  congestion,  but,  though  generally 
not  so  numerous,  are  far  more  striking. 

Among  the  more  obvious  is  a  sudden  difficulty  of  speech,  arising 
from  slight  paralysis  of  the  tongue  and  other  muscles  concerned  in 
articulation.  Words  are  not  pronounced  with  the  usual  distinctness  ; 
the  tongue  seems  to  occupy  more  space  in  the  mouth  than  it  should, 
and  is  not  moved  with  the  requisite  degree  of  promptness  and  rapidity. 

The  other  muscles  on  one  side  of  the  face  may  be  affected,  and 
hence  there  is  a  little  distortion,  lasting,  perhaps,  but  for  a  few  hours. 

Defects  of  sight  may  occur,  usually  characterized  by  the  presence  of 
dark  spots  in  the  axis  of  vision.  Such  conditions  are  due  to  minute 
extravasations  in  the  retinae,  and  are  always  of  most  serious  importance. 
I  have  known  retinal  clots  to  precede  by  more  than  a  year  the  occurrence 
of  a  more  severe  lesion. 

Bleeding  from  the  nose  is  a  common  precursor,  and,  when  occurring 
without  being  induced  by  severe  muscular  exertion,  blows,  a  dependent 
position  of  the  head,  or  other  obvious  cause  in  a  person  over  the  age  of 
forty,  is  always  to  be  regarded  as  a  symptom  of  moment. 

Numbness  limited  to  one  side  of  the  body  is  of  itself  sufficient  to 
excite  apprehension.  I  have  known  several  cases  in  which  this  symptom 
was  the  only  premonitory  sign.  It  may  be  present  several  days  before, 
or  may  precede  the  attack  by  only  a  few  minutes. 

In  addition,  there  may  be  headache,  vertigo,  slight  confusion  of 
mind,  a  tendency  to  stupor,  and  vomiting. 

None  of  the  premonitory  symptoms  may  be  present,  and  then  the 
attack,  if  of  the  apoplectic  form,  occurs  with  great  suddenness.  Even  if 
tiny  have  been  noticed,  there  is  more  or  less  of  abruptness  in  the  onset. 

Thus  the  individual  is  perhaps  standing,  engaged  in  conversation, 
when  he  is  instantaneously  struck  with  unconsciousness,  and  falls  to  tln> 
ground  as  if  shot  ;  sensibility  and  the  power  of  motion  are  abolished, 
and  no  signs  of  vitality  are  apparent  to  the  ordinary  observer,  with  the 
exception  of  the  slow  and  labored  action  of  the  heart  and  respiratory 
muscles.  The  breathing  is  stertorous,  the  li|»s  and  cheeks  are  puffed 
out  with  each  expiration,  and  the  pupils  are  generally  largely  dilated 
and  insensible  to  light. 

Reflex  movements  are  abolished  at  tirst,  hut  after  a  few  moments 
they  reappear,  and  are  even  more  readily  ezoited  than   in   health,  owing 
to  the  fact  thr>t  the  controlling  influence  of  the  brain  is  removed. 
7 


82  DISEASES  OF  THE  BRAIN. 

The  voluntary  power  of  swallowing  is  lost,  but  it  is  usually  not  dif- 
ficult to  cause  contraction  of  the  muscles  of  deglutition  by  excitation 
of  the  pharynx.  When  these  cannot  be  produced,  the  prognosis  is,  if 
possible,  increased  in  gravity,  for  the  reason  that  the  extravasation  is 
probably  in  the  medulla  oblongata,  or  so  situated  as  to  compress  it. 

The  urine  and  faeces  are  often  evacuated  involuntarily. 

An  apoplectic  attack  of  this  character  usually  terminates  in  death 
without  the  patient  recovering  his  intellect  in  the  slightest  degree.  If 
life  should  be  prolonged  for  thirty-six  hours,  the  probability  of  a  fatal 
termination  is  materially  lessened.  I  have  never  seen  a  case  of  cerebral 
haemorrhage  that  was  instantaneously  fatal,  and,  although  from  ana- 
tomical and  physiological  considerations  I  admit  the  possibility  of  such 
instances,  I  am  persuaded  that  they  must  be  rare.  Jaccoud '  expresses 
the  opinion  that  death  is  immediate  in  those  cases  in  which  the  haem- 
orrhage is  in  the  medulla  oblongata,  or  in  those  which  occur  in  both 
hemispheres.  Dr.  Hughlings  Jackson,8  on  the  contrary,  though  conced- 
ing from  theoretical  grounds  that  haemorrhage  into  or  near  the  me- 
dulla oblongata  might  cause  instant  death,  has  never  witnessed  such  a 
termination;  and  Dr.  "VVilks  8  says  that  apoplexy  is  very  rarely,  if  ever, 
a  suddenly  fatal  disease,  no  matter  what  part  of  the  brain  may  be  the 
seat  of  the  effusion.  Among  the  reports  of  several  thousand  post- 
mortem examinations  at  Guy's  Hospital,  there  was  but  one  in  which 
death  was  asserted  to  have  been  instantaneous,  and  that  was  a  case  of 
meningeal  haemorrhage.  Even  this  was  doubtful,  for  the  patient  had 
fallen  some  distance  from  the  hospital,  and  was  brought  in  dead. 

I  have  several  times  had  cases  under  my  observation  in  which,  it 
was  said,  death  had  been  as  sudden  as  though  the  individual  had  been 
struck  by  lightning  ;  but  careful  inquiry  and  post-mortem  examination 
have  either  shown  that  the  observers  were  deceived,  or  that  there  had 
been  no  extravasation  at  all,  death  being  the  result  of  heart-disease. 

Nevertheless  there  are  instances  on  record  in  which  haemorrhage 
into  the  medulla  oblongata  has  produced  death  with  as  much  sudden- 
ness as  any  other  possible  cause.  Ollivier4  cites  a  case  which  came 
under  his  observation  at  the  SalpetriSre: 

"  Batandier  (Jeanne  Elisabeth),  aged  sixty-four,  of  medium  height, 
and  inclined  to  stoutness,  was  admitted  to  the  Salpetriere,  for  attacks  of 
hysteria,  with  which  she  had  been  affected  since  her  seventeenth  year, 
when  her  menses  appeared.  These  attacks  were  very  violent,  and 
occurred  at  each  menstrual  period.  They  stopped  during  a  single 
pregnancy  at  the   age  of  thirty  years,  and  disappeared  altogether  at 

1  "  Traite  de  pathologie  interne."     Paris,  18T0.     Tome  premier,  p.  166. 

1  "  On  Apoplexy  and  Cerebral  Haemorrhage."  "  Reynolds's  System  of  Medicine."  Lon. 
don,  1868.     Vol.  ii.,  p.  520. 

*  "  Guy's  Hospital  Reports,"  1866,  p.  178. 

4  "  Trait6  des  maladies  de  la  moelle  epiniere."  Troisieme  Edition,  Paris,  1837,  tome 
!L,  p.  140. 


CEREBRAL   HEMORRHAGE.  83 

forty,  when  her  menses  ceased.  Her  intelligence  had  not  become 
seriously  impaired;  she  had  full  power  of  speech,  but  complete  deafness, 
existing  since  infancy,  rendered  this  faculty  almost  useless  to  her,  and 
she  accordingly  communicated  with  others  by  means  of  signs.  She  was 
very  irascible,  her  gait  was  irregular,  but  nevertheless  there  was  no 
paralysis.  In  all  other  respects  her  health  was  good.  On  the  28th  of 
October,  at  mid-day,  while  in  the  midst  of  a  group  of  women,  she  be- 
came very  angry,  uttered  a  cry,  leaned  against  the  wall,  and  then  fell  to 
the  ground.     She  was  raised  up,  but  was  dead. 

"  Autopsy  forty  hours  after  death.  .  .  .  The  sinuses  of  the  dura 
mater  were  gorged  with  blood,  the  pia  mater  was  strongly  injected, 
and  easily  detached  from  the  cerebral  substance  ;  the  middle  lobe  of  the 
brain  presented  a  well-marked  depression  ;  the  brain  was  firm,  and  of 
good  consistence;  the  hemispheres,  carefully  examined,  presented  a  de- 
cided injection  of  both  the  white  and  gray  substance,  but  no  hoemor- 
rhagic  foyer,  old  or  recent  ;  the  ventricles  were  empty,  the  choroid  plex- 
uses thin  and  granular  ;  the  optic  thalami  and  corpora  striata  healthy. 

"  After  having  divided  the  spinal  cord  below  the  medulla  oblongata, 
and  having  removed  the  medulla  oblongata  with  the  cerebellum,  and 
the  pons  Varolii,  a  sanguineous  clot,  irregularly  round,  and  the  size  of  a 
walnut,  was  discovered  adherent  to  the  posterior  part  of  the  medulla 
oblongata,  and  extending  above  as  far  as  the  opening  into  the  fourth 
ventricle,  which  it  entirely  closed.  The  pyramids  were  not  injured,  but 
the  olivary  bodies  were  partly  destroyed,  the  right  more  than  the  left. 
The  restiform  bodies  were  entirely  detached,  and  were  found  in  frag- 
ments in  the  middle  of  the  clot.  The  clot  was  removed  and  the  source 
of  the  haemorrhage  was  discovered  to  be  in  the  central  gray  substance, 
four  or  five  lines  below  the  inferior  border  of  the  pons  Varolii,  which 
was  a  little  softer  than  normal,  but  which  in  other  respects  appeared  to 
be  healthy,  as  did  also  the  cerebellum.  An  enormous  quantity  of  san- 
guinolent  serous  fluid  filled  the  spinal  canal,  and  flowed  out  in  part  from 
the  foramen  magnum,  and  in  part  from  the  opening  made  in  the  spine 
for  the  examination  of  the  cord,  which  was  healthy  and  non-injected. 

"  13oth  lungs  were  gorged  with  black  blood,  but  presented  no  traces 
of  emphysema;  the  right  cavities  of  the  heart  were  filled  with  black 
blood,  but  the  organ  was  healthy. 

"  All  the  abdominal  organs  were  in  a  normal  condition." 

Ollivier  remarks,  in  reference  to  this  case,  that  death  was  as  instan- 
baneoua  as  though  produced  by  a  sadden  luxation  of  the  first  or  second 
vertebra. 

Dr.  A.  Charrier '  has  reported  the  case  of  a  woman  who,  on  the 
twelfth  day  after  delivery,  died  instantaneously.     At  the  evening  visit, 

While  talking,  "she  suddenly  tittered  :i  ory,  tinned    over   on    her   pillow, 
and  was  dead.      Death    was    as    instantaneous  as   though    she    had    been 

1 "  H&norrhagie  <iu  bulbe  rachidien."     Archivm  </<•  phyniologie,  I860,  p.  660. 


84  DISEASES   OF   THE   BRAIN. 

struck  by  lightning."  At  the  autopsy  a  small  clot  was  found  in  the 
centre  of  the  medulla  oblongata.  The  rest  of  the  brain  and  the  heart 
were  perfectly  healthy. 

In  the  majority  of  cases  attended  with  complete  loss  of  conscious- 
ness, the  course  of  the  disease  is  not  so  rapid  or  hopeless  as  in  the  form 
just  described.  The  patient  falls,  is  comatose,  breathes  stertorously, 
and  presents  a  similar  general  appearance;  but  after  a  time  conscious- 
ness begins  to  return,  and  it  is  possible  to  partially  rouse  him  from  the 
condition  of  insensibility.  He  turns  over  in  the  bed,  though  with  diffi- 
cult}', and  may  attempt  to  speak.  Articulation  is,  however,  indistinct, 
for  the  muscles  of  one  side  of  the  face  are  paralyzed,  and  the  tongue, 
from  a  like  cause,  is  restricted  in  its  movements.  The  paralysis  is  found 
to  exist  in  the  limbs  of  the  same  side,  and  involves  the  loss  of  sensi- 
bility, as  well  as  of  motion,  though  rarely  to  the  same  extent.  In  some 
exceedingly  rare  cases,  perhaps  not  clearly  understood,  the  paralysis  of 
the  limbs  is  on  the  opposite  side  to  that  of  the  face.  A  man  thus  af- 
fected was  present  at  my  clinic,  in  October,  1870,  at  the  Belle vue  Hos- 
pital Medical  College.  He  was  a  patient  under  my  charge  at  the  New 
York  State  Hospital  for  Diseases  of  the  Nervous  System,  and  had  been 
attacked  several  years  previously.  His  history,  as  elicited  with  great 
care  by  my  clinical  assistant  and  resident  physician  of  the  hospital,  Dr. 
Cross,  was  perfectly  clear  on  this  point. 

The  facial  paralysis  presents  several  points  of  great  interest  in  a 
diagnostic  point  of  view.  The  affected  side  is  incapable  of  expression, 
but,  so  long  as  the  patient  does  not  attempt  any  facial  movements, 
scarcely  any  distortion  is  perceived.  Should  he  endeavor  to  open  his 
mouth  to  spit,  or  to  puff  out  his  cheeks,  the  paralysis  is  at  once  noticed. 
Owing  to  the  fact  that  the  antagonism  of  the  muscles  is  destroyed,  the 
face  is  drawn  toward  the  sound  side,  the  angle  of  the  mouth  being 
slightly  depressed.  It  is  remarkable,  however — and  the  fact  is  of  im- 
portance as  a  diagnostic  mark  between  the  facial  paralysis  of  cerebral 
haemorrhage  with  hemiplegia  and  the  simple  facial  paralysis  from  injury 
or  disease  of  the  seventh  pair — that  the  patient  does  not  lose  the  ability 
to  close  the  eye  of  the  affected  side. 

If  the  fifth  pair  of  nerves  is  involved  in  the  lesion,  sensibility  is  im- 
paired, which  is  never  the  case  in  simple  facial  paralysis,  and  the  mas- 
seter  and  pterygoid  muscles,  which  receive  their  motor  influence  from 
this  nerve,  will  consequently  be  paralyzed.  The  ability  to  masticate  on 
the  affected  side  is  therefore  lost,  and  the  cheek  hangs  lower  than  on 
the  sound  side. 

The  tongue  is  also  only  paralyzed  upon  one  side.  When,  therefore, 
it  is  protruded  from  the  mouth,  the  point  deviates  toward  the  paralyzed 
side,  owing  to  the  uncompensated  action  of  the  sound  genio-hyoglossus. 

All  these  paralyses  occur  on  that  side  of  the  body  opposite  to  the 
seat  of  the  lesion.     In  a  very  few  instances  the  paralysis  has  existed  on 


CEREBRAL   HEMORRHAGE.  85 

the  same  side  with  the  lesion.  This  is  explained  by  the  fact  that  it  oc- 
casionally happens,  as  Longet '  states,  that  the  decussation  of  the  an« 
terior  columns  of  the  cord  is  imperfect.  At  times,  again,  owing  to  a 
double  extravasation,  or  to  the  fact  that  the  lesion  is  in  the  mesial  line 
of  the  pons,  or  that  it  forces  its  way  so  as  to  involve  both  hemispheres, 
both  sides  of  the  body  are  deprived  of  motion. 

Very  inexact  ideas  have  prevailed  relative  to  the  temperature  in 
cases  of  cerebral  haemorrhage.  The  researches  of  Bourneville a  have 
given  us  more  certain  data  than  we  previously  possessed,  and,  aside 
from  their  value  as  contributions  to  symptomatology  and  pathology,  are 
of  great  importance  in  the  matter  of  prognosis.  This  observer,  as  the 
result  of  numerous  determinations,  arrived  at  the  following  conclusions: 

That  the  animal  temperature,  in  the  very  inception  of  the  apoplectic 
attack,  undergoes  a  very  considerable  reduction,  the  thermometer  in  the 
rectum  indicating  36°  (=96.8°  Fahr.),  and  even  sometimes  falling  as 
low  as  35.4°  (=95.72°  F.).  This  reduction  seems  to  be  influenced  par- 
ticularly by  the  continuance  of  the  haemorrhage  and  the  supervention 
of  additional  centres  of  extravasation.  To  this  period  of  temperature- 
depression  succeeds  another,  during  which  the  animal  heat  remains  sta- 
tionary at  its  normal  point.  If  the  patient  is  destined  to  recover,  this 
period  is  prolonged  indefinitely;  but,  if  death  is  to  ensue,  a  third  period, 
characterized  by  a  remarkable  elevation  of  temperature,  supervenes. 
During  this  stage  the  thermometer  indicates  40°  (=  104°  Fahr.),  or  may 
rise  to  41.5°  (=  106.7°  Fahr.). 

Charcot s  has  called  attention  to  the  fact  that,  in  a  few  cases  of  cere- 
bral haemorrhage,  an  acute  bed-sore  forms  on  the  buttock  of  the  para- 
lyzed side.  From  the  second  to  the  fourth  day  after  the  occurrence  of 
the  attack,  an  erysipelatous  redness  of  irregular  outline  occupies  the 
buttock,  and  frequently  extends  over  the  greater  part  of  its  surface. 
Within  forty-eight  hours  a  dark-colored  spot  appears  on  the  central 
portion,  and  the  epidermis  of  this  is  raised  by  the  sanguinolent  fluid  be- 
neath it.  This  vesicle  breaks,  and  a  sore  is  thus  formed,  which  gradu- 
ally extends.  Occasionally  but  very  rarely  the  Sore  occurs  on  the  sound 
buttock.  I  have  only  witnessed  two  cases  in  which  these  sores  were 
formed,  and  both  were  in  persons  over  seventy  years  of  age.  Of  course, 
these  eschars  are  not  to  be  confounded  with  the  bed-sores  due  to  long- 
continued  pressure. 

It  is  rarely  the  case  that  the  third  nerve  is  affected.  When  it  is, 
there  are  External  strabismus  from  paralysis  of  the  internal  rectus  muscle, 
and  ptosis  from  paralysis  of  the  elevator  of  the  upper  eyelid.  The 
pupil  is  dilated,  and  is  insensible  to  light. 

1  "  Anatomic  et  phyaiologie  (in  ayateme  in  rv.  u\,"  tome  i.,I>.  388. 

*  "  Etadea  oliniqueaet  then) i6triquea  Bar  lea  maladies  dusystomc  ncrveux."    Paria, 

1872,  p.  116. 

*  ".Sur  la  formation  rapide  d'une  eachaxe  A  la  feaae  do  0Otfl"  paralyse  dans  PhAmlpMgU 
fecente  de  cause  eerebiak'."     Archives  dc  physiologic,  1808,  p.  303. 


86  DISEASES   OF   THE   BRAIN. 

Another  phenomenon  is  sometimes  observed,  and  that  is  the  rota- 
tion of  both  eyes  toward  the  sound  side.  This  is  accompanied  by 
a  like  movement  in  the  head,  so  that,  if  the  patient  is  paralyzed  on 
the  left  side,  the  eyes  and  head  are  turned  to  the  right,  and  conse- 
quently, as  the  patient  lies  in  bed,  the  right  side  of  his  face  rests  on 
the  pillow.  I  have  observed  these  symptoms  in  about  one-third  of 
the  cases  of  cerebral  haemorrhage  which  have  come  under  my  observa- 
tion. They  were  present  from  the  very  beginning,  and  disappeared 
in  a  few  days. 

Slight  convulsive  or  involuntary  movements  are  occasionally  no- 
ticed. The  most  frequent  of  these  is  yawning,  a  symptom  which 
Dr.  Todd '  regards  as  troublesome,  and  even  unfavorable,  but  which, 
in  my  experience,  is  not  very  annoying  or  dangerous.  The  other 
convulsive  actions  mayjbe  on  the  whole  of  either  side  of  the  body,  or 
on  both  sides,  or  may  be  restricted  to  a  single  limb  or  even  a  group  of 
muscles. 

Reflex  movements  are  at  first  sometimes  abolished,  but  subse- 
quently can  generally  be  excited,  especially  in  the  lower  extremity, 
by  tickling  the  sole  of  the  foot.  Deglutition,  though  imperfect,  can 
generally  be  made  to  take  place  by  reflex  action,  unless,  as  pre- 
viously stated,  the  haemorrhage  is  in,  or  in  the  vicinity  of,  the  medulla 
oblongata. 

The  patellar  tendon  reflex  will  be  found  to  be  greatly  exaggerated 
on  the  hemiplegic  side,  and  slightly  so  on  the  sound  side.  This  latter 
is  owing  to  the  fact  that  the  motor  decussation  is  seldom,  if  ever,  com- 
plete, a  small  proportion  of  the  motor  fibres  from  the  injured  side  of 
the  brain  passing  into  the  same  side  of  the  spinal  cord,  where  they  are 
continued  in  what  is  known  as  the  "uncrossed"  or  the  "anterior" 
pyramidal  tract. 

The  ankle  clonus  can  always  be  obtained  on  the  paralyzed  side  if 
the  rigidity  and  contractures  of  the  leg-muscles  are  not  too  great. 
To  produce  this  symptom,  which  is  an  alternating  contraction  and 
relaxation  of  the  gastrocnemius,  the  weight  of  the  leg  should  be  sup- 
ported by  one  hand  while  the  other  hand  grasps  the  foot  near  the 
toes.  Sudden  and  somewhat  forcible  flexion  of  the  foot  should  then 
be  made  and  maintained,  when,  if  the  conditions  are  favorable,  the 
up-and-down  movement  of  the  foot  will  be  obtained. 

Secondary  contractures,  the  exaggeration  of  the  patellar  tendon 
reflex,  and  the  ankle  clonus,  are  all  evidences  of  irritation  of  the 
spinal  motor  tract,  and,  following  a  cerebral  haemorrhage,  indicate  a 
descending  degeneration  of  the  motor  fibres. 

Strong  tonic  contractions  of  the  muscles  of  the  paralyzed  limbs 
are  occasionally  a  prominent  phenomenon.  The  upper  extremity  is 
more  apt  to  be  their  seat  than  the  lower,  and  the  biceps  and  triceps 
1  "Clinical  Lectures."     Second  edition.     London,  1861,  p.  708. 


CEREBRAL   HAEMORRHAGE.  87 

muscles  are  especially  liable  to  be  thus  affected.  This  condition 
may  exist  at  the  very  beginning  of  the  seizure,  or  may  subsequently 
supervene. 

Few  systematic  authors  have  noticed  the  symptom  in  question — a 
symptom  which  is  not  to  be  confounded  with  the  secondary  contrac- 
tions coming  on  several  weeks  after  the  attack,  and  the  origin  of 
which  is  altogether  different — attention  seems  to  have  been  first  called 
to  it  by  Boudet,1  but  Durand-Fardel a  studied  it  more  thoroughly, 
and  was  the  first  to  determine  its  connection  with  a  definite  lesion. 
According  to  this  later  author,  primary  contraction  is  only  present 
in  cases  of  cerebral  haemorrhage  when  the  extravasation  reaches 
the  ventricles  or  the  subarachnoidal  space.  So  long  as  the  blood 
remains  circumscribed  in  the  cerebral  tissue,  there  are  no  contrac- 
tions either  in  the  paralyzed  or  the  non-paralyzed  limbs.  Of  twenty- 
six  cases  of  cerebral  haemorrhage,  in  which  death  ensued  within  one 
month,  and  in  which  the  ventricles  or  the  meninges  had  been  invaded, 
there  had  been,  in  nineteen,  contractions  of  the  paralyzed  members ; 
in  three,  contractions  of  the  sound  limbs  ;  and  in  four,  resolution 
without  contraction. 

Charcot,3  in  fourteen  cases  of  ventricular  or  meningeal  invasion, 
noticed  contractions  in  eleven,  and  in  two  epileptiform  convulsions. 
The  contractions  take  place  whether  the  membranes  be  distended  by 
the  clot,  or  whether  rupture  ensues. 

In  the  less  severe  apoplectic  form  of  cerebral  haemorrhage  now 
under  consideration,  the  urine  and  faeces  are  sometimes  passed  in- 
voluntarily from  paralysis  of  the  sphincters,  and  are  at  times  obsti- 
nately retained  from  paralysis  of  the  bladder  and  abdominal  mus- 
cles. 

The  mental  symptoms  are  at  first  scarcely  distinguishable  from 
those  which  are  present  in  the  severest  form  of  the  disease.  The 
coma  and  insensibility  arc  complete,  but  after  a  time,  which  varies 
in  duration  with  the  extent  of  the  lesion,  consciousness  begins  to  re- 
turn. The  patient  opens  his  eyes,  and  gives  a  little  attention  when 
loudly  spoken  to  ;  and  is  perhaps  able  to  express,  to  some  extent, 
his  wishes  l>y  signs  and  gestures.  Gradually  the  mental  power  in- 
creases; he  attempts  to  speak,  but  his  words  are  misplace. 1  or  for- 
gotten, and  his  articulation,  owing,  as  already  stated,  to  the  paralysis 
Of  the  face  and  tongue,  is  thick  and  indistinct.  Those  words  which 
are  enunciated  l.y  the  movements  of  the  lips  and  tongue  are  especially 

'"  Memoire  but  ['hemorrhagic  <1»^  meninges."  Journal  </<■■>•  ootmaiuaneei  midico- 
ehirurfficalea,  1889. 

I    la  contraction  dans  I'hemorrhagle  oe>6bralo."      I  iralea  d«  mtdeeine, 

l848,tomeil.,  p.  840.     Also  " Ha1adi<    des  Yieillards."    Paris,  181 

1  "NouTellea  recherohee  sur  la  pathogenic  de  LTiemoi  ''     AreMMt 

dc  physiologic,  1808,  p.  110. 


88  DISEASES   OF   THE   BRAIN. 

troublesome,  while  those  formed  in  the  throat  are  not  difficult  to  pro- 
nounce. 

The  mental  characteristics  of  the  patient  will  be  found  to  have 
ixndergone  a  radical  change.  He  is  irritable,  unreasonable,  and  fret- 
ful. His  sense  of  the  proprieties  of  life,  which  may  in  health  have 
been  very  delicate,  becomes  obtuse  ;  his  memory  is  notably  impaired, 
and  his  reasoning  power  greatly  diminished.  The  greatest  change, 
however,  is  perceived  in  the  emotional  faculties.  He  laughs  at  the 
veriest  trifles,  and  sheds  tears  profusely  at  the  least  circumstances 
calculated  to  annoy  him.  Even  for  years  afterward  this  peculiarity 
is  noticed. 

Such  is  the  first  stage  of  an  attack  of  cerebral  hemorrhage  marked 
by  apoplexy  and  paralysis,  as  ordinarily  observed  when  amendment 
takes  place.  It  is  often  the  case,  however,  that  this  stage  is  not 
fully  developed,  owing  to  the  continuance  of  the  haemorrhage.  In 
such  an  event  the  coma  becomes  more  profound,  the  breathing  more 
irregular  and  less  frequent,  the  pulse  intermits  and  loses  in  force, 
the  face  becomes  purple  from  imperfect  aeration  of  the  blood,  and 
death  ensues.  In  other  cases  a  certain  degree  of  improvement  may 
be  attained,  and  then  the  hemorrhage  may  recur,  and  the  patient  dies 
comatose. 

In  a  few  cases  which  I  have  had  under  my  charge,  the  first  symp- 
tom observed  has  been  intense  pain  in  some  part  of  the  head.  This 
has  been  quickly  followed  by  nausea  and  the  ejection  of  the  contents 
of  the  stomach.  There  have  also  been  slight  wandering  of  the  mind 
and  a  disposition  to  stagger  in  walking  These  phenomena  have  per- 
sisted for  from  four  to  six  hours,  and  then  the  patients  have  gradu- 
ally passed  into  a  comatose  condition,  with  general  resolution  of  the 
limbs.  Death  has  ensued  within  twelve  hours  after  the  beginning  of 
the  symptoms. 

In  one  of  these  cases,  that  of  a  gentleman  of  this  city,  he  had  re- 
marked to  me,  at  six  o'clock  in  the  evening,  that  he  was  feeling 
remarkably  well  all  day.  For  several  years  he  had  suffered  from  cere- 
bral hyperemia,  the  result  of  continued  and  severe  mental  applica- 
tion. At  about  eight  o'clock  he  was  seized  with  the  most  agonizing 
pain  in  the  head,  attended  with  intense  nausea.  Repeated  vomiting 
took  place,  and  there  had  been  slight  delirium  and  momentary  periods 
of  forgetfulness.  My  friend  Dr.  Lente,  of  Cold  Spring,  who  was  in 
my  house  at  the  time,  went  with  me  to  see  him,  in  response  to  his  mes- 
sage that  I  would  call.  We  found  him  as  above  described  ;  and,  as  he 
was  firmly  convinced  that  his  stomach  was  at  fault,  an  emetic  of  salt 
water  was  given  him.  It  acted  promptly,  but  without  affording  him 
the  least  relief.  A  hypodermic  injection  of  a  third  of  a  grain  of  sul- 
phate of  morphia  was  next  administered,  but  without  benefit ;  and 
this  was  followed  by  a  similar  quantity  after  half  an  hour.     He  then 


CEREBRAL   HEMORRHAGE.  89 

thought  he  might  sleep  a  little,  but  the  pain  continued.  An  hour 
afterward  I  left  him,  being  of  the  opinion,  in  which  Dr.  Lente  shared, 
that  he  was  either  suffering  from  a  cerebral  tumor  or  an  extravasation 
of  blood.  Two  hours  afterward  I  was  again  sent  for.  He  was  then 
comatose,  the  limbs  in  a  state  of  resolution,  the  breathing  of  that  loud, 
rauchous  character,  and  the  heart  beating  with  the  irregularity  so  in- 
dicative of  effusion  into,  or  in  the  neighborhood  of,  the  medulla  oblon- 
gata. Deglutition  could  not  be  excited  by  substances  placed  in  the 
mouth.  The  right  pupil  was  strongly  dilated,  while  the  left  was  a 
mere  point.     Death  ensued  within  two  hours  afterward. 

The  post-mortem  examination  was  made  the  next  day  by  Dr.  S. 
D.  Powell,  in  presence  of  Drs.  Lente,  Ripley,  Elsberg,  and  myself. 
A  clot  the  size  of  a  small  orange  occupied  the  posterior  part  of  the 
middle  and  central  portion  of  the  right  lobes.  It  was  entirely  con- 
fined to  the  white  substance.  Another,  about  as  large  as  a  hickory- 
nut,  was  situated  in  the  right  half  of  the  pons  Varolii. 

In  all  probability  the  clot  in  the  right  hemisphere  began  to  form 
first,  and  the  second,  into  the  pons  Varolii,  which  was  the  immediate 
cause  of  death,  did  not  originate  till  a  considerably  later  period,  indi- 
cated by  the  disturbances  in  the  respiration  and  circulation,  and  the 
impossibility  of  exciting  deglutition. 

In  those  cases  in  which  the  improvement  has  been  progressive  up 
to  the  point  of  partial  resumption  of  the  mental  faculties,  we  find  that 
a  second  stage  characterized  by  different  symptoms  often  supervenes. 
This  is  the  period  of  inflammation. 

It  may  begin  at  a  variable  time  after  the  occurrence  of  the  extra- 
vasation, usually  not  later  than  the  eigliih  day.  It  is  marked  by  fe- 
brile excitement  and  pain  in  the  head,  the  latter  being  oil  en  very 
severe.  There  is  gastric  derangement,  as  evidenced  by  nausea  and 
Vomiting;  and  convulsive  movements  of  the  limbs,  with  contractions 
of  the  flexors  of  the  paralyzed  side,  are  generally  present.  Delirium 
ifl  also  a  prominent  feature.  S etimes  there  is  obstinate  wakeful- 
ness, and  at  others  a  Btrong  tendency  to  coma.  This  Btage  may  last 
three  or  four  days,  or  at  mOSl   five  Or   six,  when    it    either  causes  death 

by  extension  of  the  inflammation  From  the  immediate  vicinity  of  the 

lesion   toother   parts  of  the   brain,  terminates   in    the  formation  of    an 

abscess,  or  gradually  ends  in  resolution,  with  abatement  of  the  symp- 
toms. 

Disregarding  for  the  presenl  the  firs!  two  of  these  results,  we  pro- 
ceed with  the  consideration  of  the  phenomena  of  a  case  in  which  reso- 
lution takes  place. 

With  the  cessation  of  the  inflammatory  action,  the  improvement 
of  the  patient  becomes  ver^  marked.     His  speech  i-  everj  day  more 

distinct,  his    mind  more   active,  his    paralyzed    limhs    more    capable   oi 

motion.    Usually  the  leg  recovers  power  with  much  greater  rapidity 


90  DISEASES   OF  THE   BRAIN. 

than  the  arm,  and  thus  the  patient  is  able  to  walk  tolerably  well 
before  he  can  raise  his  arm  from  his  side,  bend  the  elbow,  or 
extend  the  fingers.  The  paralysis  in  the  leg  is  most  marked  in 
those  muscles  whose  office  it  is  to  elevate  the  foot,  and  this  neces- 
sitates a  peculiar  gait  in  order  to  avoid  dragging  the  toes  along 
the  ground.  The  abductors  are  rarely  affected  to  any  great  ex- 
tent. The  patient  in  walking,  therefore,  throws  the  leg  out  from 
the  body,  and  then,  swinging  it  around,  clears  the  ground  in  this 
manner. 

In  the  upper  extremity  there  is  almost  invariably  a  disposition 
toward  contraction  of  the  pectoralis  major  and  minor  muscles,  by 
which  the  arm  is  drawn  across  the  front  of  the  thorax.  At  the  same 
time  the  latissimus  dorsi,  the  trapezius,  the  rhomboidei,  the  teres 
major  and  minor,  are  generally  in  a  state  of  relaxation,  and  eventu- 
ally tend  to  atrophy.  The  elbow  is  slightly  flexed,  the  wrist  bent 
upon  the  forearm,  and  the  fingers  drawn  in  toward  the  palm  of  the 
hand.  These  actions  may,  in  a  great  measure,  be  prevented  by  appro- 
priate treatment,  and  they  may  vary  in  extent  according  to  the  gravity 
of  the  attack.  It  is  a  curious  fact  that  the  muscles  of  respiration 
are  never  paralyzed  in  cerebral  hemorrhage  unless  the  medulla  oblon- 
gata be  involved. 

Trousseau '  has  insisted  with  great  force  on  the  fact  that,  when 
the  arm  regains  power  before  the  leg,  the  termination  is  always  fatal. 
There  is  no  foundation  for  this  theory.  Whether  the  arm  or  leg  re- 
covers first,  depends  upon  the  extent  and  situation  of  the  haemor- 
rhage. 

Now,  with  all  these  troubles  of  motility,  sensibility  may  likewise 
be  involved  to  a  greater  or  less  extent.  When  this  is  the  case,  the 
limbs  of  the  affected  side  at  first  feel  heavy  as  if  made  of  lead,  and 
after  a  while  numbness,  as  exhibited  by  a  feeling  as  if  ants  were 
crawling  over  the  skin,  or  water  trickling  over  it,  as  if  pins  and 
needles  were  sticking  in  it,  or  as  if  that  part  of  the  body  were 
"asleep,"  is  noticed.  Sometimes  the  sense  of  touch  is  greatly  less- 
ened, while  the  ability  to  feel  pain  is  scarcely  impaired,  and  indeed 
is  often  considerably  increased.  Again,  there  may  be  hyperesthesia 
of  the  skin  of  the  affected  regions,  and  pain  along  the  course  of  the 
nerves. 

The  circulation  is  inactive  in  the  paralyzed  limbs,  and  this,  to- 
gether with  the  deficient  nervous  power,  tends  to  cause  a  permanent 
reduction  of  temperature.  The  difference  may  amount  to  as  much 
as  five  or  six  degrees,  and,  as  the  ability  to  resist  cold  is  diminished, 
the  patient  is  obliged  to  use  additional  covering  on  the  paralyzed 
members. 

1 "  Lectures  on  Clinical  Medicine."  Bazire's  Translation.  Part  I.  London,  1866, 
p.  16. 


CEREBRAL   HEMORRHAGE.  91 

From  continued  disuse,  atrophy  of  the  paralyzed  muscles  always 
takes  place  unless  suitable  treatment  be  begun  at  an  early  period. 

Thus  far  we  have  only  considered  those  attacks  of  cerebral  haem- 
orrhage which  are  accompanied  with  unconsciousness.  One  of  these 
forms  kills,  without  the  patient  so  far  recovering  as  to  show  whether 
he  is  paralyzed  or  not,  though  of  course  he  is  so  to  a  profound  degree  ; 
the  other  allows  of  more  delay  ;  the  brain  can  still  act  to  some  extent, 
and,  if  death  does  not  ensue  from  continuance  of  the  haemorrhage, 
the  patient  is  found  to  be  paralyzed  on  the  side  of  the  body  opposite 
to  the  seat  of  the  brain-lesion.  One  other  form  requires  notice,  and 
it  is,  perhaps,  the  one  most  frequently  met  with.  It  differs  from  the 
attacks  just  described  in  the  important  fact  that  it  is  unattended  with 
unconsciousness. 

Like  the  others,  this  species  of  cerebral  haemorrhage  may  take 
place  very  suddenly,  without  premonitory  symptoms,  or  it  may,  like 
them,  happen  while  the  patient  is  said  to  be  asleep.  Generally,  how- 
ever, though  there  may  be  no  long  prodromatic  stage,  there  are  symp- 
toms occurring  immediately  before  the  attack  which  indicate  both 
mental  and  physical  disturbance.  These  are  headache,  vertigo,  nnmb- 
.  vomiting,  irritability  of  temper,  and,  perhaps,  slight  difficulties 
of  speech. 

When  the  attack  comes,  the  individual,  if  standing,  falls,  from  the 
immediate  paralysis  of  one  leg.  He  is  fully  sensible  of  his  condi- 
tion, although  there  is  generally  more  or  less  mental  change.  The 
arm  and  face  are  affected,  and  the  speech  is  rendered  impossible  or 
indistinct. 

If  the  patient  be  sitting  or  lying,  he  is  aware  that  something  has 
happened,  but  does  not  discover  its  exact  character  till  he  attempts  to 
rise.  A  distinguished  general  officer  of  the  army,  after  a  fatiguing 
day  of  ceremony,  entered  his  carriage  with  his  wife,  to  be  driven  to 
his  hotel.  As  he  passed  along  Fifth  Avenue  he  felt  an  indescribable 
sensation,  and  immediately  afterward  noticed  that  he  could  only  see 
the  half  of  objects.  lie  made  no  effort  to  speak,  though  he  is  con- 
fident he  did  not  for  a  moment  lose  his  consciousness.  When  he 
attempted  to  g<-t  out  of  the  carriage  he  found,  to  his  surprise,  that 
he  was  paralysed  on  the  right  Bide,  and  that  his  speech  was  so  much 
impaired  that  he  could  not  1"'  understood. 

Another  gentleman  was  reading  an  amusing  book,  at  which  he 
laughed  heartily.     lie  felt  suddenly  a  Peeling  of  vertigo,  and  the  book 

dropped  from  his  hand.  He  attempted  to  piok  it  up,  but  found  be 
had  tost  power  in  the  arm,  and,  on  trying  to  call  to  his  wife,  who  was 
in  the  same  room,  discovered  that  he  could  not  speak.  At  this  time 
he  could  walk,  but  IH  a  moment  or  two  afterward  he  fell,  from  paral- 
ysis of  his  leg.  So  far  as  the  paralysis  is  Concerned,  I  have  rarely 
seen  a' more  severe  ease  than  this. 


92  DISEASES   OF   THE  BRAIN. 

Another  went  to  bed,  perfectly  well  to  all  appearance,  having  en- 
joyed uninterrupted  good  health  for  several  years.  In  the  morning 
he  arose,  but  felt  a  little  pain  in  his  head.  As  he  stood  before  his 
glass,  he  thought  his  face  was  slightly  twisted,  and  he  noticed  as  he 
was  shaving  himself  that  he  did  not  feel  the  razor  on  one  side.  While 
he  was  testing  his  facial  mobility  and  sensibilit)7,  he  experienced  a 
trace  of  numbness  in  his  left  hand.  This  gradually  increased,  and  in 
addition  the  limb  lost  power.  In  a  few  minutes  he  could  not  move  it 
at  all.  By  the  time  I  saw  him — two  hours  afterward — the  paralysis 
had  extended  to  the  leg.  At  no  period  was  there  insensibility  or 
mental  confusion. 

A  gentleman  retired  at  night  in  good  health.  On  attempting  to 
get  out  of  bed  he  discovered  that  he  was  paralyzed  in  the  leg.  Nei- 
ther the  arm  nor  the  face  was  affected. 

In  the  case  of  a  gentleman  of  this  city  whom  I  saw  in  consultation 
with  Dr.  W.  M.  Polk,  and  who  had  for  several  years  suffered  from 
frequent  severe  headaches  and  other  cerebral  symptoms,  the  only  phe- 
nomenon was  binocular  hemianopsia,  with  occasional  slight  delirium. 
Dr.  H.  Knapp,  who  saw  the  patient  before  I  did,  discovered  no  altera- 
tions in  the  functions  or  structure  of  the  eye,  and  we  all  agreed  that 
the  case  was  one  of  very  slight  cerebral  haemorrhage. 

Several  cases  have  been  under  my  care  in  which  only  the  face  or 
the  tongue  was  paralyzed  ;  others  in  which  the  arm  alone  was  in- 
volved ;  and  others,  like  the  one  just  mentioned,  in  which  the  symp- 
toms were  confined  entirely  to  the  leg.  Sometimes  there  was  a  mo- 
mentary feeling  of  vertigo,  sometimes  a  vacant  stare,  something  like 
that  of  the  petit  mal  of  epilepsy,  sometimes  a  slight  degree  of  intel- 
lectual confusion,  sometimes  headache,  and,  again,  no  head-symp- 
toms whatever.  The  subsequent  progress  of  such  attacks  requires 
no  special  consideration  beyond  that  already  given  to  the  more  severe 
forms. 

Now,  no  matter  how  light  the  attack  may  have  been,  nor  how 
rapid  the  improvement,  the  patient  who  has  had  cerebral  haemorrhage 
is  never  mentally  or  physically  the  same  as  he  was  before.  If  the 
seizure  has  not  been  severe,  he  may  advance  so  far  toward  a  complete 
cure  as  to  evince  very  little  disorder  of  his  mind  or  body.  But  close 
observation  shows  that  he  is  not  entirely  restored,  and,  though  he  may 
do  very  -well  for  light  intellectual  and  physical  exertion,  severe  labor 
of  either  kind  is  beyond  his  powers — and  no  one  is  more  sensible  of 
this  fact  than  himself.  Even  after  years  his  emotions  are  abnor- 
mally excitable.  A  patient  in  the  New  York  State  Hospital  for  Dis- 
eases of  the  Nervous  System  informed  me  that  he  shed  tears  every 
time  a  funeral  passed  him,  and  that  even  hearing  of  any  one's  death, 
or  reading  the  obituary  column  in  a  newspaper,  caused  his  feelings 
to  get  the  better  of  him.     In  the  lightest  forms  of  the  attack,  this 


CEREBRAL   HyEUORRIIAGE.  93 

easily-aroused  emotional  disturbance  is  a  marked  feature  for  years 
subsequently,  if  it  ever  entirely  disappears.  And  as  regards  the  mus- 
cles which  have  been  paralyzed,  it  is  very  certain  that,  though  they 
may  be  made  strong  enough  for  all  practical  purposes,  they  never  can 
be  restored  to  their  former  sound  condition. 

The  character  and  general  mental  type  of  tbe  individual  usually 
undergo  some  change  ;  and  this  may  be  to  the  extent  of  reversing  his 
ordinary  traits. 

Causes. — Advanced  age  is  one  of  the  most  influential  circumstances 
which  predispose  to  an  attack  of  cerebral  haemorrhage,  and  this  fact 
has  long  been  known.  Thus  Hippocrates  *  states  that  apoplexy  is 
most  common  between  the  ages  of  forty  and  sixty,  and  modern  inves- 
tigation establishes  the  truth  of  tbe  proposition  as  regards  the  actual 
number  of  cases.  It  is  probable,  however,  that  the  liability  increases, 
as  Dr.  Flint2  says,  from  the  age  of  twenty  upward,  and  that  there  are 
not  so  many  cases  occurring  in  persons  over  sixty  as  below,  for  the 
reason  that  the  number  of  individuals  alive  of  that  age  is  less. 

Of  three  hundred  and  eighty-three  cases  of  cerebral  haemorrhage 
which  have  been  under  my  professional  care,  at  some  time  or  other 
after  the  occurrence  of  the  extravasation,  in  my  private  and  hospital 
practice,  and  in  which  tbe  age  of  the  patient  is  noted,  three  hundred 
and  forty-one  occurred  in  persons  over  forty  years  of  age.  Of  these, 
three  hundred  and  eleven  were  between  forty  and  sixty,  thirty-three 
between  sixty  and  seventy,  five  between  seventy  and  eighty,  and  three 
over  eighty. 

Of  the  thirty-one  cases  in  persons  under  forty,  twenty  were  be- 
twesn  forty  and  thirty,  ten  between  thirty  and  twenty,  and  one  un- 
der twenty.  This  latter  was  a  boy  of  seventeen,  whom  I  exhibited 
at  my  clinic  at  the  Bellevue  Hospital  Medical  College  in  the  autumn 
of  1870. 

The  disease  is  certainly  more  common  among  men  than  women, 
though  some  authors  have  asserted  the  contrary.  Falret  ascertained 
that,  of  twenty-two  hundred  and  ninety-seven  eases,  sixteen  hundred 
and  sixty  occurred  in  males  and  only  six  hundred  and  thirty-seven  in 
females.  In  my  own  experience,  of  three  hundred  and  eighty-three 
oases,  two  hundred  and  fifty-nine  were  in  males  and  one  hundred  and 
twenty-four  in  females. 

Temperament    and  organization  are  supposed   to  have  an  influence 

in  predisposing  to  cerebral  hemorrhage.     It  was  formerly  thought 

thai   those  Of  Sangaine  temperament  and  plethoric  habit  who  bad  stout 

bodies,  large  heads,   florid    complexions,   ami    short,    thick    necks,  were 

especially  liable ;  but  more  exact   and  thorough  investigation  would 

1  "Aphorisms,"  chapter  vi.,  aphorism  57. 

*  "A  Treatise  on  the  Principles  and  Practice  of  Bfedldne."  Third  edition,  Philadel- 
phia, ,1868,  p.  582. 


94  DISEASES   OF  THE   BRAIN. 

appear  to  show  that  such  is  not  the  case,  and  that  thin  and  pale  indi- 
viduals show  fully  as  great  a  proclivity.  Dr.  Flint1  expresses  the 
opinion  that  there  is  no  special  apoplectic  constitution,  and  my  own 
experience  is  decidedly  to  the  same  effect. 

That  the  tendency  to  cerebral  haemorrhage  is  often  hereditary 
appears  to  be  very  certainly  established.  Within  my  own  knowledge, 
I  am  aware  of  several  striking  instances  which  support  this  opinion. 
A  gentleman  consulted  me  for  hemiplegia,  the  result  of  cerebral 
haemorrhage,  whose  grandfather,  father,  two  uncles,  two  brothers, 
and  one  sister  had  died  of  this  disease,  and  whose  son,  thirty-six 
years  of  age,  had  been  attacked.  In  another  case  a  lady  had  her 
father,  two  brothers,  and  one  sister  die  of  the  disease ;  and,  in  a  third 
very  remarkable  case,  the  great-grandfather,  grandmother,  father,  four 
uncles  and  aunts,  and  two  brothers,  all  in  a  direct  line,  died  of  cere- 
bral haemorrhage. 

Piorry2  cites  the  case  of  a  woman,  herself  paralytic,  wrhose  three 
children  had  died  of  convulsions,  and  whose  mother,  uncle,  and  broth- 
ers and  sisters,  to  the  number  of  twelve,  had  died  of  cerebral  haemor- 
rhage or  convulsions.  It  has  very  often  happened  in  my  experience  that 
the  father  or  mother  of  a  hemiplegic  patient,  whose  condition  resulted 
from  cerebral  haemorrhage,  had  been  affected  in  a  similar  manner. 

As  regards  the  influence  of  diseases  of  the  heart,  Legallois,  Briche- 
teau,  Rostan,  Andral,  and  Bouillaud3  adduce  instances  in  support  of 
the  existence  of  a  definite  relation.  While  others,  among  whom  Ro- 
choux,  Walshe,  and  Flint  are  to  be  placed,  deny  the  existence  of  any 
such  causative  influence.  As  tending  to  produce  active  or  passive 
cerebral  congestion,  disease  of  the  left  or  right  side  of  the  heart  would 
reasonably  seem  to  be  conducive  to  the  occurrence  of  cerebral  haemor- 
rhage. The  tension  of  the  blood  in  the  vessels  of  the  brain  is  in- 
creased thereby,  and  the  liability  to  the  rupture  of  a  diseased  vessel 
rendered  greater. 

The  condition  of  life  has  also  been  supposed  to  exert  an  effect  in  pre- 
disposing to  cerebral  haemorrhage,  it  being  asserted  by  some  authors 
that  the  affection  is  much  more  common  with  the  rich,  and  those  living 
in  ease,  luxury,  and  refinement,  than  in  the  poor  and  laboring  classes. 

It  is  difficult  to  arrive  at  any  very  definite  conclusion  on  this  point, 
owing  to  very  obvious  reasons,  but  I  am  inclined  to  think  the  theory 
to  be  not  well  founded.  It  is  only  necessary  to  visit  our  large  hos- 
pitals, to  see  how  many  of  the  inmates,  drawn  as  they  generally  are 
from  the  laboring  classes,  are  suffering  from  cerebral  haemorrhage  or 
its  effects. 

Thus  far  we  have  only  considered  the  more  important,  intrinsic, 

1  Op.  eit.,  p.  583. 

2  "  De  l'heredit6  dans  les  maladies,"  p.  107. 

3  "  Truite  dc  clinique  des  maladies  du  carnr,"  second  edition,  tome  ii.,  p.  580. 


CEREBRAL   HEMORRHAGE.  95 

predisposing  causes  ;  there  are,  however,  others  which  may  be  called 
extrinsic. 

Season  is  one  of  the  chief  of  these.  The  disease  is  much  more 
common  in  winter  than  in  the  other  seasons,  although  some  statistics 
would  seem  to  show  more  cases  during  summer.  A  careful  examination 
of  such,  however,  shows  that  under  the  head  of  apoplexy  is  included 
not  only  cerebral  haemorrhage,  but  congestion,  sunstroke,  embolus,  and 
in  fact  nearly  every  other  affection  attended  with  sudden  loss  of  con- 
sciousness. My  own  researches  have  been  very  exact  on  this  point,  and 
as  their  results  I  find  that,  of  the  three  hundred  and  eighty-three  cases 
of  which  I  have  notes,  one  hundred  and  forty  cases  occurred  in  winter, 
eighty-one  in  spring,  ninety -seven  in  summer,  and  fifty-eight  in  autumn. 
It  has  been  noticed,  too,  that  sudden  variations  of  temperature,  especially 
from  mild  to  cold  weather,  increase  the  number  of  cases  of  cerebral 
haemorrhage. 

Of  the  exciting  causes,  a  long  list  can  readily  be  made.  Among 
them  are  the  excessive  use  of  alcoholic  liquors  and  other  stimulating 
substances;  the  use  of  opium  in  excess  ;  the  ingestion  of  large  quantities 
of  food,  especially  such  as  is  stimulating  and  indigestible  ;  excessive 
physical  or  mental  exertion,  strong  emotional  disturbance,  such  as  anx- 
iety, extreme  joy,  anger,  or  terror  ;  the  act  of  coition,  especially  in  old 
people ;  straining  at  stool ;  enlarged  prostate,  or  paralysis  of  the 
bladder,  requiring  strong  muscular  efforts  for  the  evacuation  of  the 
urine  ;  childbirth  ;  tight  clothing  about  the  neck,  chest,  or  abdomen  ; 
certain  occupations  which  require  the  head  to  be  depressed  ;  vomiting, 
sneezing,  coughing,  and  laughing  ;  exposure  to  the  direct  rays  of  the 
sun  or  other  sources  of  great  heat ;  the  sudden  arrest  of  a  custom- 
ary flux,  such  as  hemorrhoidal  bleeding ;  the  sudden  application  of 
cold  water  to  the  body  ;  long-continued  bathing  in  very  warm  water  ; 
the  circumstance  that  the  patient  has  had  a  previous  attack,  and  certain 
diseases,  as  gout  and  syphilis. 

In  regard  to  some  of  these  causes,  I  may  state  that  several  very  in- 
teresting cases  have  occurred  in  my  own  practice.  In  one,  a  lady  was 
attacked  on  hearing  that  her  cook  had  left  herj  in  another  the  emotion 
excited  by  the  fall  of  a  picture  from  the  wall  caused  a  Beizure.  Four 
cases  produced  by  straining  at  stool  have  come  under  my  observation. 
In  one  of  thrill  a  gentleman  well  known  in  public  life  retained  sufheient 
consciousness  and  intelligence  to  take  a  large  key  ou1  of  his  pocket  with 
the  non-paralyzed  hand,  and  bo  rap  on  the  floor  for  assistance. 

Two  cases  occurred  during  Bezual  intercourse,  one  in  a  man,  the 
other  in  a  woman.  In  one  of  these  there  was,  subsequently,  a  great 
inorease  of  venereal  desire.     In  one  ease,  the  seizure  was  induced  by 

stooping  over  to  tie  the  si This  was  in  (ho  boy,  seventeen  years  of 

age,  already  mentioned.  It  must  be  confessed,  however,  that  very  fre- 
quently, perhaps  in  the  majority  of  cases,  no  immediate  cause  can  be 


96  DISEASES  OF  THE  BRAIN. 

reasonably  alleged.  Of  the  three  hundred  and  eighty-three  cas^s  noted 
by  myself,  no  cause  was  noted  in  two  hundred  and  ten. 

Relative  to  the  influence  of  sleep,  I  am  by  no  means  in  accord  with 
those  authors  who  regard  it  as  a  powerful  exciting  cause.  During  sleep 
the  quantity  of  blood  circulating  in  the  cerebral  blood-vessels  is  dimin- 
ished, and  hence  there  is  less  tension  upon  their  walls  than  during  wake- 
fulness. I  doubt  very  much  whether  cerebral  haemorrhage  ever  occurs 
during  healthy,  undisturbed  sleep. 

But  there  is  a  condition  which  supervenes  upon  sleep,  and  which,  to 
ordinary  observers,  presents  the  usual  phenomena  of  sleep,  but  which  is 
really  a  very  different  state,  both  as  regards  the  brain  and  the  symp- 
toms— and  that  is  stupor  due  to  venous  congestion.  In  this  affection 
there  is  an  increase  of  the  pressure  upon  the  brain,  produced  by  the  over- 
distended  vessels ;  and  hence  coma,  to  some  extent,  ensues.  This  state 
is  characterized  by  difficulty  of  awaking  the  individual,  by  turgescence 
of  the  larger  veins  of  the  neck,  by  a  more  or  less  purple  hue  of  the  face, 
by  snoring,  and  by  the  puffing  out  of  the  lips  and  cheeks  in  breathing. 
Both  of  these  latter  phenomena  are  due  to  paralysis. 

In  this  condition  it  is  not  unusual  for  cerebral  haemorrhage  to  occur, 
but  the  existing  state  is  not  sleep. 

So  far  as  my  own  experience  extends,  I  have  not  found  a  majority  of 
the  cases,  where  I  have  examined  into  this  point,  to  have  taken  place 
either  during  sleep  or  the  stupor  to  which  I  have  referred.  I  have  made 
it  a  rule,  not  only  in  those  cases  of  cerebral  haemorrhage  which  have  been 
under  my  own  care,  but  all  others,  in  which  I  could  do  so,  to  inquire 
particularly  with  reference  to  the  matter  in  question,  and  have  found 
that,  in  three  hundred  and  eighty-five  out  of  four  hundred  and  sixty- 
seven  cases,  the  individuals  were  awake  at  the  time  of  the  attack. 

Doubtless  much  of  the  confusion  has  arisen,  not  only  from  the  non- 
discrimination of  sleep  from  stupor,  but  also  from  treating  of  apoplexy 
as  a  disease  instead  of  regarding  it  as  a  symptom  due  to  several  very 
different  pathological  conditions  of  which  cerebral  haemorrhage  is  only 
one,  and  of  which  embolism,  thrombosis,  congestion,  meningeal  hem- 
orrhage, and  epilepsy,  are  others. 

Finally,  it  may  be  said  of  the  etiology,  that  whatever  tends  to  in- 
crease the  flow  of  blood  to  the  head,  or  to  retard  its  exit,  is  capable  of 
acting  as  an  immediate  cause  of  cerebral  haemorrhage. 

Diagnosis. — The  diagnosis  of  cerebral  haemorrhage  is  ordinarily  not 
difficult,  but  it  must  be  confessed  that  one  or  two  affections  are  very 
liable  to  be  confounded  with  it,  and  the  attendant  circumstances  sur- 
rounding a  patient  in  a  condition  of  insensibility  may  be  such  as  to 
materially  increase  the  obstacles  to  the  formation  of  a  correct  opinion. 

Thus,  supposing  an  individual  to  be  found  in  a  state  of  profound  in- 
f  ensibility,  the  condition  may  be  due  to  compression  from  injury  of  the 
skull,  to  concussion  from  a  fall  or  blow,  to  congestion,  to  asphyxia,  to 


♦  CEREBRAL   HEMORRHAGE.  97 

syucope,  to  a  recent  epileptic  fit,  to  uraemic  intoxication,  to  hysteria,  to 
narcotism,  or  to  drunkenness. 

A  mistake  of  either  of  these  states  for  cerebral  hemorrhage  would 
be,  in  the  end,  embarrassing  to  the  physician,  and  perhaps  injurious  to 
the  patient. 

The  coma  might  also  be  the  result  of  embolism,  of  thrombosis,  of 
tumor,  of  abscess,  or  of  meningeal  hemorrhage  ;  but,  as  regards  these 
conditions,  no  opprobrium  could  be  attached  to  the  physician,  or  harm 
come  to  the  patient,  by  any  error  of  diagnosis,  although  a  regard  for 
scientific  exactness  should  always  prompt  us  to  be  as  specific  as  possible 
in  our  inquiries  and  examinations. 

From  asphyxia,  cerebral  haemorrhage  is  distinguished  by  the  fact 
that  in  the  former  the  respiration  is  suspended.  The  cause  is  often 
apparent.  A  careful  examination  of  the  cranium,  and  a  survey  of  the 
surrounding  circumstances,  will  enable  the  physician  to  ascertain  the 
existence  or  non-existence  of  compression  from  traumatic  cause.  This 
cause  may  either  be  depression  of  bone,  the  rupture  of  an  internal 
blood-vessel,  or  the  entrance  of  some  foreign  body,  as  a  bullet,  into  the 
interior  of  the  skull.  So  far  as  symptoms  are  concerned,  there  might 
be  considerable  difficulty  in  diagnosticating  either  of  these  accidents 
from  cerebral  haemorrhage,  but  the  history  would  render  a  mistake  im- 
possible. 

Concussion  presents  more  difficulties,  because  the  comatose  person 
may  be  found  in  such  a  situation  as  to  warrant  the  opinion  that  he  has 
fallen  from  a  height,  or  otherwise  received  a  blow  on  the  head,  when  in 
fact  he  is  suffering  from  cerebral  haemorrhage.  But  if  he  has  fallen  from 
a  height  or  been  struck,  there  will  probably  be  more  severe  bruises  about 
his  person  than  if  he  is  affected  with  cerebral  haemorrhage,  and  there  may 
be  bleeding  from  the  ears  or  nose — symptoms  of  cranial  injury  not  met 
with  in  the  latter  condition. 

If,  however,  the  individual  has  fallen  from  a  height,  he  may  have 
done  BO  in  consequence  of  an  extravasation  of  blood  in  his  brain,  and 
,ie  may  present  all  the  marks  of  suffering  simply  from  the  concussion, 
or  lie  may  have  fractured  skull  with  compression.  It  is,  therefore,  im- 
possible to  make  a  cornet  diagnosis  hi  all  cases,  or  to  lay  down  any 
oertain  rules  which  will  constitute  infallible  guides.  It  is  perfectly 
possible  to  meet  with  cases  such  as  those  referred  to,  in  regard  to  which 
no  human  judgment  can  be  certainly  correct.  Such  instances  are  of 
course  rare,  and  accordingly,  in  the  great  majority,  the  ciroumstanoea  and 
the  presumption  will  generally  lead  to  a  correct  opinion. 

From  congestion  of  the  apoplectiform  variety  cerebral  haemorrhage 
can  generally  be  distinguished  without  much  difficulty.     The  absence  of 

stertorous   breathing,   the    short    duration   of    the    coma,    the    transient 
character  of  the  paralysis,  the  contraction  of  the  pupils,  the  fact  that 
die  loss  of  sensibility  and  the  power  of  motion  are  not  generally  confined 
8 


98  DISEASES   OF   THE   BRAIN. 

to  one  side  of  the  body,  and  the  longer  continuance  of  premoniton 
symptoms,  will  be  sufficient  indications  of  the  existence  of  congestion. 
Syncope  is  distinguished  by  the  circumstances  that  the  respiration  and 
circulation  are  both  diminished  in  power  if  not  suspended,  that  there  is 
no  hemiplegia^  that  the  face  is  pale,  the  skin  cold,  and  that  these  phe- 
nomena are  all  transitory  in  character.  The  history  of  the  case  will  also 
assist  us  in  arriving  at  a  correct  judgment. 

Epilepsy,  if  seen  from  the  beginning  of  the  paroxysm,  cannot  be 
mistaken  for  cerebral  haemorrhage,  nor  this  latter  for  epilepsy,  if  the 
onset  of  the  attack  has  been  witnessed.  Even  if  there  are  convulsions 
present  in  the  apoplectic  seizure,  the  error  could  not  readily  be  com- 
mitted if  attention  be  paid  to  the  attendant  phenomena.  For  there  is 
no  biting  of  the  tongue,  the  convulsions  are  persistent,  and  the  animal 
heat  is  lowered,  whereas  in  epilepsy  the  temperature  rises  at  once  and 
remains  high — 105°  Fahr.  or  thereabouts,  during  the  convulsive  stage. 
But  the  person  found  in  a  comatose  condition,  with  no  previous  history 
to  guide  us,  may  be  supposed  to  be  either  in  the  comatose  stage  of  an 
epileptic  paroxysm,  or  to  be  laboring  under  a  seizure  due  to  extravasa- 
tion of  blood.  In  such  a  case,  if  the  fit  has  been  epileptic,  foam  will 
be  found  around  the  mouth,  and  perhaps  blood  from  injury  of  the 
tongue  or  cheek.  Moreover,  the  stupor  of  epilepsy  is  not  usually  of  long 
duration,  and  is  not  generally  characterized  by  stertorous  breathing. 

In  uraemia,  the  coma  of  which  is  very  similar  to  that  resulting  from 
cerebral  haemorrhage,  the  history  of  the  case  is  our  chief  reliance  for  a 
correct  diagnosis,  though  the  absence  of  hemiplegia  and  the  general 
presence  of  anasarca  are  of  course  of  great  value.  Moreover,  in  very 
doubtful  cases  the  urine  may  be  drawn  off  by  the  catheter,  and  exam- 
ined for  albumen  and  tube-casts.  If  these  are  present,  the  probability 
of  the  stupor  being  due  to  Bright's  disease  and  uraemic  intoxication  is 
very  much  increased.  The  fact,  also,  that  in  uraemia  there  is  a  pro- 
gressive fall  of  the  animal  temperature — as  low  as  91.5°  Fahr.  being 
reached  —  and  that  there  is  no  subsequent  elevation,  are  important 
points  in  this  connection. 

Coma  is  sometimes  a  manifestation  of  hysteria,  but  a  very  little 
acquaintance  with  the  phenomena  of  this  condition  will  suffice  to  pre- 
vent mistakes.  In  some  cases  of  hysterical  coma  there  is  well-marked 
hemiplegia;  but  even  when  this  complication  is  present,  the  facts  that 
the  hysterical  diathesis  exists,  that  there  have  probably  been  other  mani- 
festations of  hysteria,  that  the  pulse  is  small,  weak,  and  frequent,  and 
that  the  breathing  is  free  from  stertor,  will  enable  a  correct  diagnosis 
to  be  formed. 

In  narcotism  the  condition  often  bears  a  close  resemblance  to  that 
due  to  cerebral  haemorrhage.  But  in  the  former  there  is  no  hemiplegia, 
the  pupils  are  generally  contracted,  the  respiration  is  not  stertorous, 
and  the  coma  comes  on  gradually. 


CEREBRAL   HEMORRHAGE.  99 

Drunkenness  and  cerebral  haemorrhage  are  often  confounded.  I  have 
known  some  sad  mistakes  of  the  kind  to  be  made,  both  by  professional 
and  non-professional  persons,  many  of  which  were  unavoidable,  for  it 
must  be  confessed  that  there  are  great  difficulties  connected  with  the 
subject.  The  habit  of  drinking  alcoholic  liquors  is  so  general  that  no 
reliance  can  be  placed  upon  the  test  of  smelling  the  breath.  A  person 
may  have  just  taken  a  glass  of  wine  or  of  brandy,  and  be  seized  with 
extravasation  of  blood  in  his  brain  immediately  afterward,  and  when  not 
in  the  least  intoxicated.  And,  even  if  dead-drunk,  he  may  at  the  same 
time  have  cerebral  haemorrhage.  In  such  a  case  as  the  latter,  discrimi- 
nation would  be  impossible.  In  ordinary  cases  of  alcoholic  intoxication 
the  patient  can  generally  be  roused  to  some  extent;  the  pupils  are 
dilated,  but  this  latter  is  often  the  case  in  hemorrhage;  the  breathing 
is  usually  free  from  stertor,  but  some  drunkards  always  snore;  the  pulse 
is  -mall  and  weak,  and  there  is  no  hemiplegia.  "When  all  these  symptoms 
are  in  accord,  there  will  be  little  difficulty;  when  they  are  not,  the 
physician  must  be  guarded  in  his  expressions  of  opinion,  and  diligently 
inquire  into  the  personal  characteristics  of  the  patient  and  all  matters 
bearing  on  the  history  of  the  case. 

From  the  centric  diseases  previously  mentioned,  the  diagnosis  of 
cerebral  haemorrhage  is  easy  as  regards  some,  and  difficult  as  to  others 
Thus,  from  embolism  it  cannot  in  many  cases  be  distinguished  in  the 
first  stage.  But  when  all  the  phenomena  are  taken  into  consideration 
the  chance  of  error  is  very  much  diminished.  Embolism  is  generally 
accompanied  with  disease  of  the  left  side  of  the  heart,  and  there  is  often 
a  history  of  rheumatism  ;  there  are  never  any  premonitory  head-symp- 
toms ;  it  occurs  in  young  persons  as  well  as  old  ;  for  reasons  which  will 
be  explained  when  the  subject  of  partial  cerebral  anaemia  from  embolism 
is  considered,  the  resulting  hemiplegia  is  generally  on  the  right  side  ; 
the  paralysis  usually  disappears  iii  a  few  hours  alter  the  attack  ;  if  it 
do  -  not,  there  is  do  gradual  improvement,  as  in  cerebral  haemorrhage  ; 
there  are  no  contractions  or  partial  convulsions1;  there  are  slight  or 
no  changes  <>f  temperature;  and  there  is  more  frequently  delirium. 

The  gradual  development  of  the  symptoms  in  t  brombi  >sis,  tumor  or 
abscess,  and  the  frequency  with  which  convulsions  ensue  in  the  tatter 
diseases,  together  with  the  associated  symptoms,  will  prevent  the  coma 
whioh  sometimes  exists  being  mistaken  for  the  stupor  of  cerebral  ha-m 
orrhage. 

During  the  subsequent  stages  of  cer<  bra!  iuemorrhage,  when  the 
mental  condition  and  the  hemiplegia  are  the  most  prominent  features, 
inquiry  into  the  antecedent  history  will  bring  out  the  foregoing  points, 
and  assist  us  in  arriv  ing  at  a  correct  idea  of  the  cause.      fiven,  h  >W< 

1  Jaccoud  [op.  cit.,  p,  ill)  so  asserts,  though  I  have  seen  one  case  in  which  post- 
mortem examination  revealed  the  presence  of  an  embolus  En  the  middle  cerebral  artery. 
and  in  which  there  had  been  convulsions. 


100  DISEASES   OF   THE   DRAIN". 

should  we  be  baffled  in  this  respect,  no  great  inconvenience  could  result 
either  to  the  patient  or  physician. 

Prognosis. — The  prognosis  depends  upon  the  extent  or  situation  of 
the  haemorrhage,  and  refers  to  the  probability  of  saving  life  during  the 
period  of  attack  and  immediately  afterward,  and  of  curing  or  mitigating 
the  subsequent  paralysis. 

In  the  severe  apoplectic  form,  death  is  almost  inevitable;  so  far  aa 
my  experience  goes,  it  is  the  invariable  result.  It  generally  takes  place 
within  a  few  hours.  If,  however,  life  be  prolonged  till  the  fourth  day, 
there  is  some  hope.  Irregularity  of  pulse,  or  one  very  rapid,  impossi- 
bility of  swallowing,  involuntary  evacuation  of  the  fasces,  and  cold 
sweats,  render,  if  possible,  the  prognosis  still  more  unfavorable. 

In  the  apoplectic  form  attended  with  paralysis,  the  gradual  increase 
of  the  coma  and  hemiplegia  indicate  the  continuance  of  the  haemor- 
rhage, and  are  consequently  of  grave  importance.  About  one-third  of 
those  attacked  with  this  form  die.  The  prognosis  is  bad  in  proportion 
to  the  debility  and  age  of  the  patient,  and  the  circumstances  under 
which  the  attack  has  occurred.  Thus,  if  it  has  supervened  in  a  person 
who  has  had  no  obvious  exciting  cause,  the  probability  is  that  there  is 
serious  disease  of  the  blood-vessels,  whereas,  coming  on  in  a  young  per- 
son as  the  result  of  severe  muscular  exercise,  or  mental  strain,  the  prog- 
nosis is  more  favorable.  A  second  attack  is  more  apt  to  prove  fatal 
than  a  first,  and  a  third  than  a  second,  and  so  on. 

In  the  mild  form  characterized  by  paralysis,  but  no  loss  of  conscious- 
ness, the  prognosis  is  generally  favorable.  It  must  be  recollected,  how- 
ever, that  the  risk  of  inflammation  is  quite  great,  both  in  this  and  the 
apoplectic  form  with  paralysis,  and  that  the  patient  is  not  safe  from  it 
till  after  the  eighth  day. 

And  in  both  forms,  if  the  temperature  rise  above  100°  Fahr. ;  if  the 
respiration  be  chiefly  abdominal;  if  the  patient  is  unable  to  swallow; 
and  rattling  of  mucus  is  heard  in  the  throat,  the  prospect  of  recovery  is 
bad.  The  same  may  be  said  of  pain  in  the  head  and  contractions  of  the 
paralyzed  muscles.  If,  further,  as  Bourneville  has  shown,  the  tempera- 
ture reaches  104°  Fahr.,  death  is  inevitable. 

As  regards  the  probability  of  recovery  from  the  paralysis,  much  de- 
pends upon  the  opportunities  the  patient  may  have  for  receiving  proper 
medical  treatment.  The  tendency  is  generally  toward  amendment  even 
in  the  worst  cases.  Gradually  the  speech  improves,  the  breathing  be- 
comes better,  and  the  arm  acquires  more  strength;  but  the  improve- 
ment often  stops  here,  and  never  goes  on  unaided  to  complete  recovery. 
The  longer  the  paralysis  has  lasted,  the  less  prospect  there  is  of  great 
progress  under  any  treatment;  and,  if  strong  contractions  producing 
distortions  have  taken  place,  the  prognosis  is  unfavorable. 

Certain  muscles  r&  over  better  than  others.     The  extensors  of  the 


CEREBRAL   HAEMORRHAGE.  101 

foot  and  hand  are  especially  intractable,  but,  as  a  rule,  those  of  the 
lower  extremity  improve  more  rapidly  than  those  of  the  upper. 

The  mind  ordinarily  improves,  pari  passu  with  the  physical  symp- 
toms, though  not  always.  I  have  witnessed  several  exceptions  to  the 
rule.  Even  in  slight  cases  the  intellect  may  suffer  to  a  great  extent, 
and  in  no  case  is  it  ever  in  all  respects  as  good  as  before  the  attack. 
Among  the  unfavorable  signs  are,  persistent  irritability  of  temper,  fail- 
ure of  memory,  and  the  existence  of  delusions.  Difficulties  of  speech, 
whether  as  regards  the  memory  of  words,  or  the  ability  to  coordinate 
the  muscles  of  speech,  so  as  to  pronounce  them  properly,  are  often  very 
persistent.  I  have  now  under  my  care  a  gentleman  who  was  attacked 
with  cerebral  haemorrhage  two  years  ago,  whose  physical  powers  are 
quite  good,  and  whose  mind  is  not  seriously  impaired,  but  who  cannot 
yet  remember  sufficient  words  to  carry  on  an  ordinary  conversation. 
When  the  difficulty  is  simply  due  to  paralysis  of  the  tongue  and  facial 
muscles,  the  prognosis  is  more  favorable. 

Morbid  Anatomy. — The  seat  of  the  extravasation  from  cerebral  haem- 
orrhage may  be  in  the  substance  of  the  cerebral  tissue,  or  in  the  ven- 
tricles.    The  former  is  much  the  more  common. 

Now,  the  blood,  which  is  poured  out  from  a  ruptured  vessel  into  the 
substance  of  the  brain  must,  of  course,  occupy  its  place  by  separating 
or  lacerating  the  fibres.  It  thus  forms  for  itself  a  cavity,  which  en- 
larges as  the  haemorrhage  goes  on,  until  at  last  the  resistance  to  further 
separation  or  laceration  may  be  so  great  as  to  overcome  the  tension  of 
the  blood,  and  thus  put  a  stop  to  the  bleeding. 

The  shape  of  the  cavity  varies  according  to  the  manner  by  which  it 
has  been  produced.  When  it  is  formed  by  the  separation  of  the  cere- 
bral fibres,  it  is  generally  elongated;  whereas,  when  produced  by  lacera- 
tion, it  is  oval,  round,  or  irregular  in  form.  The  situation  of  the  haem- 
orrhage modifies  the  form  of  the  cavity.  In  the  hemisphere  it  is  usually 
round;  in  the  motor  tract,  irregular  or  oval.  The  variations  as  regards 
size  are  great.  I  have  seen  clots  no  larger  than  a  pea,  and  again  as 
large  as  an  orange.  When  haemorrhage  occurs  in  the  motor  tract,  tin 
olol  is  almost  invariably  small;  whereas,  in  the  hemispheres,  in  tin-  cere- 
bellum, or  in  the  ventricles,  it  is  large. 

A  clot  does  not  always  consist  of  Mood  alone  Brain-tissue  is  very 
often  mixed  with  it,  and  this  is  especially  the  ease  when  the  extravasa- 
tion has  been  into  tho  white  substance  of  the  hemispheres. 

Gintrac1  has  collected  the  data  of  five  hundred  and  sixty  eases  of 
cerebral  hemorrhage,  in  whioh  there  was  a  single  dot,  and  in  these  tho 
■eat  of  the  extravasation  is  shown  in  the  following  table  ! 

1  "Trait*4  theorique  h  pratique  dea  maladiei  do  Pappareilnenreui  "  Tome  deudtae 
Paris,  1869.    Art  ''  Hemorrhagica  du  oerreau." 


102  DISEASES   OF   THE   BRAIX. 

Corpora  striata 72 

Optic  thalami 38 

Corpora  striata  and  optic  thalami  simultaneously 48 

Middle  lobes  of  the  brain 12*7 

Pons  Varolii  and  crura  cerebri 78 

Cerebellum 36 

Ventricles 46 

Posterior  lobes  of  the  brain 33 

Anterior  lobes  of  the  brain 17 

Medulla  oblongata 2 

Corpus  eallosum •. 1 

Cortical  substance  of  the  brain 45 

Total 560 

The  ordinary  seat  of  cerebral  haemorrhage  is  thus  seen  to  be  in  the 
vicinity  of  the  motor  tract,  for  in  nearly  one-half  of  the  total  number 
of  cases  the  lesion  was  situated  either  in  the  corpora  striata,  the  optic 
thalami,  the  pons  Varolii,  the  crura  cerebri,  or  the  medulla  oblongata. 
And  of  these  j)arts  the  corpora  striata  and  optic  thalami  are  preemi- 
nently liable.  As  the  lesion  is  seldom  confined,  to  these  organs,  the  in- 
ternal capsule  rarely  escapes  injury.  Next  in  order  of  frequency  come 
the  middle  lobes. 

In  the  great  majority  of  the  cases  of  cerebral  haemorrhage  the  lesion 
is  situated  primarily  in  the  gray  substance.  This  is  probably  due  to 
the  fact  of  the  greater  vascularity  which  this  tissue  possesses.  It 
would  appear,  too,  that  even  when  the  extravasation  is  not  into  the 
corpus  striatum  or  optic  thalamus,  it  is  very  apt  to  be  in  the  immediate 
vicinity  of  these  organs.  M.  Duret '  has  given  an  anatomical  expla- 
nation of  this  fact,  which  appears  to  be  satisfactory.  According  to  this 
observer,  the  arteries  of  the  corpus  striatum,  which  are  given  off  gen- 
erally from  the  middle  cerebral  artery,  though  sometimes  from  the 
anterior  cerebral,  enter  the  brain  through  the  anterior  perforated  space. 
A  few  delicate  branches  go  to  the  caudate  nucleus  of  the  corpus  stri- 
atum, but  the  larger  ramifications  are  distributed  sometimes  to  the 
lenticular  nucleus,  but  more  generally  they  wind  around  this  organ, 
and  give  origin  to  branches  which  are  widely  distributed,  reaching 
even  as  far  as  the  island  of  Reil.  Thus  the  largest  intra-cerebral 
arteries  are  situated  in  the  external  portion  of  the  corpus  striatum. 
And  this  is  the  exact  place  where,  according  to  Charcot,  cerebral 
haemorrhage  is  most  apt  to  occur. 

Gendrin2  had  previously  remarked  that  the  extravasation  in  cases 
of  cerebral  haemorrhage  almost  always  comes  from  the  branches  of  the 
middle  cerebral  artery.  The  middle  lobe,  the  island  of  Reil,  the  corpus 
striatum,  and  the  optic  thalamus  are  nourished  through  this  vessel,  and 

1  "  Note  Bur  la  distribution  des  arteres  nourricieres  du  ccrveau."  Mouvement  me- 
dical, 187:'.,  p.  27.  Also,  "Recherches  anatomiques  sur  la  circulation  de  l'enc6phalc." 
Archives  de  physiologic,  187  J,  p.  316. 

2  "  Traitc  philosophique  de  medecine  pratique.''     Paris,  1838,  to:ne  i.,  p.  1  18. 


CEREBRAL   ILEMORRIIAGE.  103 

hence  the  great  preponderance  of  extravasation  in  these  portions  of 
the  encephalic  mass. 

It  has  also  been  observed — and  Durand-Fardel '  calls  special  atten- 
tion to  the  circumstance — that  cerebral  haemorrhage  has  a  manifest  ten- 
dency to  be  developed  and  directed,  rather  toward  the  central  than  the 
peripheral  parts  of  the  brain.  It  is  thus,  to  say,  centripetal  in  its  course, 
in  which  respect  it  differs  from  cerebral  softening,  which  is  not  less 
evidently  centrifugal — the  peripheral  regions  showing  a  greater  ten- 
dency than  the  central  to  be  affected  by  this  morbid  process. 

The  right  side  of  the  brain  appears  to  be  more  frequently  the  seat  of 
cerebral  haemorrhage  than  the  left.  Thus,  on  consulting  Gintrac,2  we 
find  that  in  three  hundred  and  sixty-nine  cases  in  which  the  side  on 
which  the  lesion  was  situated  was  noted,  the  parts  were  affected  in 
the  order  of  frequency  shown  in  the  following  table : 

Eight.  Left. 

Corpus  striatum,  optic  thalamus,  and  these  bodies  simultaneously  73  63 

Middle  lobes 63  52 

Pons  Varolii 10  10 

Cerebellum 14  12 

Cortical  substance 15  8 

Posterior  lobes 18  15 

Anterior  lobes 6  10 

Total 199  170 

The  right  side  had  thus  a  numerical  superiority  of  twenty-nine  over 
the  left.  It  will  be  observed,  also,  that  in  no  one  part  did  the  left  side 
predominate  except  in  the  case  of  the  anterior  lobe.  On  the  other  hand, 
Durand-Fardel,3  from  an  examination  of  one  hundred  and  seventeen 
cases  of  haemorrhage  into  the  hemispheres,  found  that  the  right  side  was 
the  seat  in  forty-nine,  the  left  in  fifty-seven,  and  both  sides  in  eleven  in- 
stances. Of  eleven  cases  of  cerebellar  haemorrhage,  the  right  lobe  was 
affected  six,  the  left  five  times,  and  the  middle  lobe  twice. 

Generally  there  is  but  one  recent  extravasation,  but  occasionally  two 
or  more  occur  simultaneously,  or  at  least  so  near  to  each  other  in  point 
'if  time  as  to  be  essentially  contemporaneous  acts  of  one  morbid  pro- 
cess. Of  one  hundred  and  thirty-nine  cases  cited  by  Durand-Fardel,4 
twenty-one  were  multiple;  eighteen  of  these  were  double,  and  three 
triple.  In  my  own  experience  two  cases  of  triple  lesions  have  occurred, 
hkI  two  of  double  Lesions.  Of  the  triple  cases  the  right  corpus  st ria- 
tum,  right  middle  lobe,  and  left  middle  lobe,  were  the  seats  in  one,  and 
the  right  and  left  corpora  striata,  and  left  anterior  lobe,  in  the  other. 
Of  the  double,  cases  the  seats  in  one  were  the  right  corpus  striatum, 
and  righl  middle  lobe,  and  in  the  other  the  righl  middle  and  posterior 
lobe  and  right  half  of  the  pons  Varol'i. 

1  "Traitc"'  pratique  dea  maladies  dea  rleillard  ."     Paris,  1878,  p,  181, 

•'  Op.  ,/  /-■<•.  ,-;/.  7..  ./'.,  p,  1-:..  1  Op.  .;/,  p.  1-'',. 


104  DISEASES   OF   THE   BRAIN. 

It  sometimes  happens  that  the  mass  of  extravasated  blood  breaks 
through  the  cortical  substance  of  the  brain,  and  appears  immediately 
under  the  pia  mater  and  arachnoid;  or  these  membranes  may  give  way, 
and  the  blood  be  effused  into  the  space  between  them  and  the  dura 
mater.  In  a  very  few  of  these  cases  the  blood  comes  primarily  from 
the  cortical  substance  of  the  brain,  but  in  the  greater  number  the  ex- 
travasation originates  more  deeply  and  reaches  the  surface  by  lacer- 
ating the  easily-torn  white  tissue.  The  blood  in  these  cases  undergoes 
coagulation  much  more  rapidly  than  when  it  remains  in  the  cerebral 
substance,  unless  the  base  of  the  brain  be  the  seat,  in  which  case  it  often 
remains  fluid. 

The  extravasation  takes  place  into  the  ventricles  in  about  one-half 
of  all  the  cases.  The  lateral  or  fourth  ventricle  may  be  the  seat,  or 
it  may  exist  in  both  of  the  former.  The  blood  extravasated  into  the 
ventricles  remains  liquid  a  longer  time  than  when  effused  into  any 
other  part.  This  is  probably  due  to  the  fact  that  it  is  subjected  to  the 
action  of  the  ventricular  fluid,  by  which  its  physical  properties  aro 
altered. 

In  the  majority  of  cases  of  haemorrhage  into  the  ventricles,  the 
blood  comes  originally  from  the  corpus  striatum,  or  optic  thalamus, 
but  it  may  also  be  derived  from  the  choroid  plexus,  from  the  septum 
lucidum,  or  from  the  walls  of  the  ventricles.  Sometimes  it  is  im- 
possible to  determine  its  point  of  origin.  It  may  enter  the  ventricle 
through  a  small  opening,  in  which  case  the  foyer  is  distinct,  or  the 
wall  of  the  ventricle  may  be  largely  lacerated  and  so  broken  down  that 
the  foyer  and  the  ventricle  constitute  essentially  but  one  cavity.  The 
septum  lucidum  is  not  infrequently  torn,  and  the  two  lateral  ventricles 
are  thus  converted  into  one  cavity. 

As  regards  what  may  be  called  the  secondary  consequences  of  an 
extravasation  of  blood  into  the  cerebral  substances,  we  find  that  when 
it  is  large  the  convolutions  are  flattened  against  the  walls  of  the  cranium, 
the  membranes  are  usually  dry,  and  a  distinct  feeling  of  fluctuation  can 
often  be  detected.  In  several  cases  I  have  known  a  large  extravasation 
to  cause  by  its  own  weight  a  complete  rupture  of  the  lobe  in  which  it 
existed,  through  the  handling  required  in  removing  the  brain  from  the 
skull. 

At  other  times  the  membranes  are  evidently  congested;  the  brain- 
tissue,  when  incised,  exhibits  an  increased  number  of  red  points,  and  the 
subarachnoidean  or  ventricular  liquid  may  be  largely  augmented  over 
the  normal  quantity. 

The  state  of  the  arteries  is  a  most  important  and  interesting  subject 
for  examination,  but,  as  it  has  an  immediate  and  direct  relation  with 
the  pathogeny  of  cerebral  hemorrhage,  it  will  be  more  properly  consid- 
ered under  the  head  of  pathology. 

Extravasated    blood   undergoes    certain    changes.       Instead   of    di- 


CEREBRAL   HAEMORRHAGE.  105 

viding  into  two  parts,  the  clot  and  the  serum,  as  does  blood  when 
exposed  to  the  atmosphere,  it  remains  for  a  time  homogeneous  and 
gelatiniform.  About  the  fifth  or  sixth  day  it  separates  into  two  parts  ; 
the  one,  the  serum,  is  absorbed  by  the  surrounding  tissue;  the  other, 
consisting  mainly  of  the  fibrine  and  the  red  corpuscles,  contracts  and 
becomes  hard.  By  the  fifteenth  day  it  has  become  fibrinous  in  texture, 
and  is  changed  from  its  former  black  hue  to  a  yellow  color.  Micro- 
scopic examination,  made  at  any  period  during  these  changes,  reveals 
the  presence  of  red  corpuscles,  crystals  of  hematoidin  and  sometimes  of 
cholestrin.     It  never  entirely  disappears. 

In  the  earlier  period  of  the  extravasation,  the  walls  of  the  cavity 
are  rough,  and  discolored  with  blood.  But,  as  the  changes  are  going 
on  in  the  clot,  the  walls  likewise  alter  in  appearance  ;  the  inequalities 
and  irregularities  disappear,  and  a  new  formation  of  connective  tissue 
lines  the  cavity.  Blood-vessels  appear  in  it,  and  aid  in  the  absorption 
of  the  fluid  portion  of  the  extravasated  blood.  As  the  process  of 
separation  and  absorption  goes  on,  the  cavity  contracts  upon  its  con- 
tents, and  eventually  forms  a  cicatrix  which  incloses  the  remains  of 
the  clot.  This  cicatrix  is  generally  of  a  yellow  color,  and  firm  in 
texture. 

Sometimes,  however,  absorption  does  not  take  place.  The  con- 
traction of  the  walls  of  the  cavity  does  not  therefore  ensue,  and  it 
remains  distended  with  more  or  less  altered  blood.  This  may  be  the 
starting-point  of  secondary  lesions,  or  a  new  haemorrhage  may  occur 
into  the  same  cavity,  or  an  abscess  may  result. 

Pathology. — The  theory  of  cerebral  haemorrhage  brings  us  to  the 
consideration  of  several  important  points.  One  of  the  first  questions 
to  be  solved  is,  Can  the  rupture  of  a  vessel  of  the  brain  take  place — 
not  including  traumatic  causes — unless  the  vessel  is  in  a  diseased 
condition?  Both  sides  of  this  proposition  have  their  adherents.  On 
the  one  part,  it  is  urged  that  cerebral  hemorrhage  never  lakes  place 
spontaneously  unless  the  walls  of  the  bleeding  vessel  have  been  so 
injured  by  disease  as  to  destroy  their  strength  and  elasticity  ;  on  the 
other,  that  it  is  perfectly  possible  for  a  blood-vessel  to  give  way,  owing 
to  the  increased  tension  of  the  blood  or  disease  <»t'  the  peri-vascular 

tissue,  without   the  walls  of  the  vessel  itself  being  in  the  least   diseased. 

While  admitting  that,  in  the  majority  of  cases,  the  structure  of  the 
yielding  vessel  will  be  found  to  be  impaired,  I  am  satisfied  that  either 
of  the  other  two  causes  may  produce  a  rupture.      The  reasons    for  this 

opinion  will  be  apparent  in  the  course  of  the  following  remarks. 

One  of  the  most  common  diseases  to  which  the  cerebral  arteries  are 

liable  is  chronic  endarteritis,  a  condition  which  has  been  well  described 
by  Virchow,' and  which  is  particularly  apt  to  be  met  with  in  those  who, 

1  "  Ocber  die  Erweiterung  kleinerer  Gef&sse."  Archiv  filr path,  A/mt.  uud  Physiol., 
B.  III.,  isis,  and  "Cellular-pathologte,"  Berlin,  1871,  8.  158  etacq. 


106  DISEASES   OF   THE   BRAIN. 

from  age  or  other  debilitating  influence,  have  had  their  nutrition 
impaired.  As  the  consequence  of  this  state,  the  vessels  lose  their 
elasticity,  become  brittle,  and  are  therefore  often  unable  to  bear 
the  ordinary  tension  of  the  blood,  much  less  any  severe  strain. 

This  disease  may  terminate  in  fatty  degeneration  of  the  arterial 
walls,  or  this  last  condition  may  be  the  primary  affection.  Fatty 
degeneration,  like  chronic  endarteritis;  is  most  commonly  met  with 
in  badly-nourished  persons,  but  who  are  at  the  same  time  cachectic. 
The  inner  coat  is  the  point  of  origin,  and  hence  it  sometimes  hap- 
pens that  this  and  the  middle  coat  give  way,  leaving  the  external 
coat  entire,  and  thus  forming  an  aneurism.  But  Bouchard,1  who 
has  examined  into  this  matter  with  great  minuteness,  denies  that 
such  aneurisms  are  ever  found,  and  asserts  that  the  so-called  aneuris- 
mal  sac  consists  of  the  lymphatic  membrane,  lining  the  cavity  in  the 
perivascular  tissue,  through  which  the  vessel  passes ;  and  that  the 
blood,  in  such  cases,  has  already  ruptured  the  vessel.  In  reality,  how- 
ever, there  is  no  haemorrhage  into  the  cerebral  tissue  till  this  mem- 
brane gives  way. 

In  a  subsequent  memoir,  by  MM.  Charcot  and  Bouchard,2  this  point 
is  still  more  thoroughly  considered,  and  the  opinion  expressed  that  cere- 
bral haemorrhage  is  almost  invariably  due  to  what  they  call  miliary 
aneurisms,  which  are  the  result  of  arteritis,  and  which  are  not  neces- 
sarily preceded  by  atheroma. 

The  existence  of  these  minute  aneurisms  was  first  pointed  out  by 
Cruveilhier,s  and  was  subsequently  recognized  by  Calmeil.4  Meynert '' 
appears  also  to  have  noticed  them,  and  Heschel  *  discovered  them  in  the 
pons  Varolii;  but  no  one  previous  to  Charcot  and  Bouchard  called  at- 
tention to  the  relation  which  they  bear  to  cerebral  haemorrhage.  On 
March  16,  1866,  while  examining  the  foyer  of  a  recent  extravasation 
into  the  brain,  they  perceived,  on  the  walls  of  the  cavity  in  the  cerebral 
tissue,  two  small  globular  masses  attached  to  a  minute  vessel.  These 
were  miliary  aneurisms.  One  was  ruptured,  and  its  contents  were  in 
immediate  relation  with  the  mass  of  extravasated  blood  constituting  the 
apoplectic  clot.  Previously  to  this  time  these  observers  had  noticed 
these  aneurisms,  but  not  before  had  they  associated  them  with  the 
pathogeny  of  cerebral  haemorrhage  ;  since  then,  in  numerous  commu- 

1  "  Etudes  sur  quclques  pointea  do  la  pathogenic  des  hemorrhagica  cerebralcs." 
Paris,  1866. 

2  "  Nouvelles  recherches  sur  la  pathogenic  do  l'hemorrhagc  cerebrale."  Archives  ele 
•pliy&iologie  normale  et pathologique,  1868,  pp.  110-643. 

3  "  Anatomic  pathologique  du  corps  humain,"  liv.  xxxiii.,  PI.  2,  Fig.  S. 

4  "  Trait'.'  des  maladies  Lnflammatoires  du  cervcau."     Paris,  1859,  tome  ii.,  p.  522. 

5  "  Ueber  Gcfasscntartungen  in  der  Varolsbriickc  uud  den  Gehirnschenkclm." 
AUgemeine  Wiener  Wochenschrift,  No.  28,  186U. 

6  "  Die  Capillar-Aneurysmen  irn  Tons  Varolii."  Wiener  mediciniscJie  Wochenschrift, 
September,  1865. 


CEREBRAL   HAEMORRHAGE. 


107 


nications,  they  have  called  attention  to  the  importance  of  their  dis- 
covery, and  its  value  is  generally  acknowledged  by  neuro-pathologists. 


i# 


In  the  accompanying  woodcut  (Fig.  8),  taken  from  Bouchard's  mem- 
oir, is  represented  one  of  these  aneurisms  which  has  been  ruptured 


Fig.  9. 


V 


into  a  bcBmorrhagio  <-l<>t  :  a,  the  aneurism  ;  J,  the  clot  ;  c,  <■,  the  torn 
perivascular  <>r  lymphatic  Bheath. 

Fig.  '.)  \<  from  the  drawing  of  a  vessel  which  I  recently  dissect- 
ed out  of  the  pons  Varolii,  into  the  righl   lobe  <>f  which  a  large  ex- 


108  DISEASES   OF   THE   BRAIN. 

travasation  had  taken  place.  Both  lohes  were  studded  with  these 
aneurisms  ;  they  were  also  found  in  the  convolutions  in  the  optic 
thalami  and  corpora  striata,  and  in  the  white  substance  of  both  hemi- 
spheres ;  a  large  extravasation  had  also  taken  place  into  the  right 
hemisphere. 

In  sixty-nine  cases  of  cerebral  haemorrhage  in  which  post-mor- 
tem examinations  were  made,  atheroma  was  found  but  in  fifteen, 
or  twenty-two  per  cent.,  while  these  miliary  aneurisms  were  met 
with  in  every  case.  They  appear  as  little  globular  masses  in  the 
small  intracranial  vessels,  and  are  in  size  from  one-tenth  of  a  milli- 
metre to  one  millimetre.  If  they  contain  liquid  blood,  they  are 
red  ;  but  if  the  blood  be  coagulated,  the  color  is  dark,  almost  black 
in  some  cases.  In  the  order  of  frequency,  they  are  found  in  the 
optic  thalami,  the  corpora  striata,  the  convolutions,  the  tuber  annu- 
lare, the  cerebellum,  the  centrum  ovale,  the  crura  cerebri,  and  the 
medulla  oblongata. 

According  to  Charcot  and  Bouchai-d,  the  arteritis,  which  re- 
sults in  the  formation  of  these  aneurisms,  is  diffuse  in  charac- 
ter. It  is  found  not  only  in  the  minute  artery,  which  is  the  sub- 
ject of  the  aneurismal  dilatation,  but  extends  to  the  entire  system 
of  minute  intracranial  vessels.  This  arteritis  is  in  some  respects 
analogous  with  what  Rokitansky  described  under  the  name  of  chronic 
peri-arteritis,  and  is  characterized  by  disease  of  the  membrane,  desig- 
nated by  Robin  as  the  perivascular  sheath,  and  by  His  as  the  lym- 
phatic sheath.  There  are  also  lesions  cf  the  adventitious  tunic  and 
of  the  muscular  and  internal  coats.  The  diseased  action  proceeds 
from  without  inward,  and  hence  the  name  of  peri-arteritis  is  a  very 
proper  one. 

Charcot  and  Bouchard  claim  that,  with  the  following  exceptions, 
all  cases  of  cerebral  haemorrhage  are  the  result  of  the  rupture  of 
miliary  aneurisms,  viz.,  fracture  with  depression  ;  the  haemorrhages 
which  result  from  thrombosis  of  the  sinuses,  and  those  which  occur  in 
the  course  of  certain  depraved  states  of  the  system.  While  admit- 
ting that  the  majority  of  cases  of  cerebral  haemorrhage  have-  this 
origin,  I  am  not  prepared  to  go  so  far  as  these  observers  in  ascrib- 
ing all  not  embraced  in  the  three  categories  of  exceptions  above 
specified,  as  being  due  to  this  cause.  I  had  recently  the  opportu- 
nity of  convincing  myself  that  this  explanation  of  the  pathogeny  of 
cerebral  haemorrhage  is  too  absolute  ;  for,  on  examining  the  brain  of 
a  patient  who  had  died  from  an  extravasation  of  blood  into  the  left 
corpus  striatum,  optic  thalamus,  and  left  lateral  ventricle,  not  a  sin- 
gle miliary  aneurism  could  be  discovered,  although  they  were  care- 
fully sought  for  in  all  parts  of  the  brain.  The  patient,  a  lady  forty- 
three  years  of  age,  had  suffered  from  repeated  attacks  of  acute 
rheumatism,  had   frequently  been  affected  with   headache   and   ver- 


CEREBRAL   HAEMORRHAGE.  109 

tigo,  and  had  been  seized  with  apoplexy  while  in  the  water-closet. 
She  had  been  the  subject  of  heart-disease  for  over  twenty  years.  I 
had  only  the  brain  submitted  to  me  for  examination,  but  all  the  arte- 
ries of  this  organ  were  in  a  state  of  atheromatous  degeneration,  and  I 
was  able  to  find  what  appeared  to  be  the  vessel,  or  one  of  them,  which 
had  given  way  and  produced  the  extravasation.  The  accompanying 
engraving  (Fig.  10)  represents  this  artery  as  seen  with  an  inch  object- 
ive. It  is  perceived  that  several  of  the  aneurismal  dilatations  have 
given  way  ;  the  internal  coat  of  this,  as  well  as  of  other  arteries,  was 

Fig.  10. 


m 


found,  by  microscopical  examination,  to  be  in  a  state  of  fatty  degen- 
eration; the  same  state  existed  in  the  middle  coat,  and  the  external 
coat  was  thickened  and  friable. 

Lancereaux '  reports  a  very  similar  case,  of  which,  as  it  has  an  im- 
portant bearing  on  the  subject,  I  cpiote  the  summary  which  he  gives 
(page  424): 

"  Haemorrhage  into  the  left "  [right  is  evidently  meant,  and  it  is  so 
stated  on  page  252,  where  the  full  report  of  the  case  is  given]  "  corpus 
striatum,  producing  an  irruption  into  the  lateral  ventricles,  and  arteritis, 
albuminuria,  cardiac  hypertrophy. 

'•  A  woman,  aged  fifty-eight,  died  a  few  days  after  an  attack  charac- 
terized by  left  hemiplegia,  diminution  of  sensibility,  and  vomiting.  The 
autopsy  revealed  tlie  existence  of  a  hemorrhagic  clot  at  the  exterior 
and  posterior  part  of  the  corpus  striatum,  which,  after  having  separated 
this  ganglion  from  the  optic  thalamus,  had  broken  into  the  ventricular 
cavity.  The  nervous  tissue,  besides  being  torn,  was  colored  yellow, 
through  the  infiltration  of  h.ematine  into  its  substance.  The  ventricles 
contained  a  small  quantity  of  liquid  blood.  There  existed  under  the 
ependyma  of  the  posterior  comu  of  the  right  ventricle  a  hemorrhagic 

punctat  ion,  and    a    Sanguineous    suffusion    extended    over  the   whole  cir- 

Dumferenoe  of  the  cerebellum.    The  entire  encephalic  mass  was  injected. 

The    walls    of    the    cerebral    arteries    were    thick    and    opa'pie.       (hi    the 
1  "AnatomU  pathologlque,"  u-xtr,  pp.  'J.vj  and  484;  atlas,  plates  -t  and  L9 


110  DISEASES   OF   THE   BRAIN.     ' 

branches,  even  those  of  the  smallest  size,  were  perceived  moniliferous 
dilatations,  the  result  of  a  primitive  alteration  of  the  arterial  wall, 
and  the  probable  points  of  origin  of  the  haemorrhage.  The  aorta 
was  affected  with  endarteritis  throughout  its  whole  extent,  the  aortic- 
orifice  was  slightly  insufficient,  and  the  left  ventricle  was  markedly 
hypertrophied  ;  the  renal  arteries  were  indurated,  rigid,  and  calca- 
reous. The  kidneys,  small,  atrophied,  and  granular,  were  affected 
with  interstitial  nephritis.  The  arterial  system  was  involved  through- 
out almost  its  entire  extent." 

It  would  appear,  therefore,  that  we  cannot  set  aside  the  results  ob- 
tained by  Virchow  and  others,  and  that,  in  the  present  state  of  our 
knowledge,  it  is  safe  to  adopt  the  opinion  expressed  by  Durand-Fardel,2 
that,  although  "  the  facts  observed  as  described  by  MM.  Charcot  and 
Bouchard  have  undoubted  value,  it  would,  nevertheless,  be  premature 
to  attribute  to  miliary  aneurisms  an  exclusive  part  in  the  production  of 
cerebral  haemorrhage." 

The  condition  of  the  perivascular  tissue,  or  the  brain-substance,  has 
much  to  do  with  the  occurrence  of  haemorrhage.  One  reason  why  ex- 
travasation more  frequently  occurs  in  the  brain  than  in  the  liver,  for 
instance,  is,  that  its  tissue  is  softer,  and  therefore  not  capable  of  giving 
as  much  support  to  the  blood-vessels  as  is  the  latter  organ.  Now,  when 
the  cerebral  substance  is  softened  by  disease  in  any  part,  the  natural 
support  of  the  vessels  of  that  part  is  still  further  lessened,  and  the  ten- 
dency to  haemorrhage  increased.  Again,  in  the  condition  sometimes 
met  with  in  old  people,  in  wThich  the  brain  becomes  atrophied,  the  ves- 
sels may  undergo  dilatation  and  subsequent  rupture.  This  view  is  op- 
posed by  Jaccoud,3  but  in  one  case  of  cerebral  haemorrhage,  terminating 
in  death,  and  in  which  I  had  the  opportunity  of  making  a  post-mortem 
examination,  the  right  hemisphere,  the  seat  of  the  extravasation,  was 
very  considerably  atrophied,  and  weighed  three  ounces  and  a  quarter 
less  than  the  left.  The  possibility  of  the  existence  of  this  cause  may, 
therefore,  be  admitted,  although  it  cannot  be  considered  as  definitely 
established.  The  researches  of  Cotard 3  would  appear  to  show  that  cere- 
bral haemorrhage  is  not  infrequently  a  cause  of  partial  atrophy  of  the 
brain. 

In  the  next  place,  the  state  of  the  blood,  as  regards  quality  and 
tension,  must  be  considered.  There  can  be  no  doubt  that  certain  dis- 
eases affecting  the  general  system  .may  so  deteriorate  the  blood  as  to 
render  it  unfit  to  properly  nourish  the  blood-vessels,  and  hence  their 
tissue  is  more  readily  broken  down.  Among  these  conditions  are 
typhus,  scurvy,  chlorosis,  gout,  and  syphilis. 

The  tension  of  the  blood  in  the  vessels  is  subject  to  constant  va- 

1  Op.  cit.,  p.  2G2. 

2  Op.  cit,  p.  155. 

z  "Etude  sur  l'atrophic  partiellc  du  cervcau,"  Pari*,  1868. 


CEREBRAL   HEMORRHAGE.  HI 

nation  from  the  operation  of  many  physical  and  mental  causes,  and 
may,  through  their  action,  be  so  increased  as  to  overcome  the  resist- 
ance afforded  by  the  vascular  walls.  These  influences  have  been  suf- 
ficiently considered  in*  the  section  on  causes,  and  need  not,  therefore, 
be  dwelt  upon  here  at  any  length.  My  own  opinion  of  their  sufficien- 
cy, without  preexisting  disease  of  the  blood-vessels,  to  produce  rupt- 
ure and  extravasation,  has  been  formed  after  much  observation 
and  reflection.  Analogous  phenomena  take  place  every  day,  and  are 
not  supposed  to  be  due,  in  any  extent,  to  vascular  disease.  Thus 
nasal  haemorrhage  occurs  from  strong  muscular  exertion  of  such  a 
character  as  to  retard  the  flow  of  blood  from  the  brain,  from  emo- 
tional or  other  kind  of  mental  excitement,  and  from  hypertrophy 
of  the  left  side  of  the  heart,  by  which  the  amount  of  blood  in  the 
cerebral  vessels  is  increased.  All  these  causes  augment  the  tension, 
and  it  would  be  singular  if  at  times  a  healthy  intracranial  vessel 
did  not  give  way  through  their  influence,  as  well  as  one  outside  of 
the  skull. 

Differential  Diagnosis. — A  point  of  very  great  importance  re- 
mains to  be  considered  as  a  part  of  the  pathology,  and  that  is  whether 
it  is  possible  or  not  to  determine  during  life  in  what  part  of  the 
brain  an  extravasation  has  taken  place.  While  I  am  afraid  we  can 
not  be  as  explicit  in  this  matter  as  is  desirable,  I  am  very  sure 
we  can  often,  from  a  careful  study  of  the  symptoms,  arrive  at  con- 
clusions more  or  less  accurate,  and  can  sometimes  determine  the 
question  with  absolute  certainty.  The  great  difficulty  is,  that  we 
are  not  yet  sufficiently  acquainted  with  the  physiology  of  the  sev- 
eral parts  of  the  brain,  and  hence  are  not  able  to  ascribe,  with  as 
much  8ureness  as  is  desirable,  variations  from  healthy  action,  to  de- 
rangement of  the  proper  anatomical  part  of  the  cerebral  mass.  Be- 
sides,  when  the  extravasation  is  large,  although  it  may  he  strictlv 
COnfined  to  the  anatomical  limits  of  the  ganglia  or  part  of  the  en- 
cephalic mass  in  which  it  originates,  it  may  act  by  transmitted  press- 
ure upon   OOntigUOUS  ganglia  OX   parts,   and    hence   the  symptoms  are 

rendered  complex-. 

As  we  have  Been,  haemorrhage  is  more  liable  to  take  place  within 
the  ganglia  bordering  on  the  motor  tract  thin  any  other  pari  of  the 

brain.      This    is    mainly  due  to  the  fact    that    this   is   the  most   vascular 

part  of  the  cerebral  substance. 

Generally  speaking,  when  the  clol    is  Btrictly  limited  to  either  of 

'he  nuclei  of   the  corpus   striatum,  the   paralysis,  however  extensive   it 

may  have  been  in  the  first  place,  is  of  a  transitory  character.  More- 
over, there  i<  no  tendency  to  the  production  of  muscular  contractions 
at  a  late  period  of  the  disease. 

And  there  are  instances  «m  record  in  which  there  has  been  extravasa- 
tion into  the  corpus  striatum,  and  no  paralysis  of  any  part  of  the  body. 


112  DISEASES   OF   THE   BRAIN. 

Gintrac,1  of  forty  cases  collected  by  him,  found  apparent  absence  of 
paralysis  in  five.  But  he  admits  that  this  number  may  perhaps  be  re- 
duced, for  one  of  the  cases  was  that  of  an  infant  one  day  old,  and  the 
other,  that  of  an  old  man  eighty  years  of  age,  who  had  had  a  cerebral 
luemorrhage  ten  years  before  his  death,  in  both  of  which  an  exact  di- 
agnosis of  this  point  could  not  have  been  otherwise  than  difficult.  But 
in  one  of  the  others  there  was  no  paralysis,  and  yet  after  death  a  clot 
as  large  as  a  pigeon's  egg  was  discovered  in  the  left  corpus  striatum. 
In  the  second  there  was  no  actual  paralysis,  but  a  weakness  and  trem- 
bling of  the  right  arm.  The  post-mortem  examination  revealed  the 
existence  of  a  clot,  as  large  as  an  almond,  in  the  left  corpus  striatum. 
The  third  was  for  a  few  moments  deprived  of  the  power  of  speech,  but 
he  had  equal  muscular  strength  on  both  sides.  Then  he  became  weak 
and  died,  without  having  been  actually  paralyzed.  After  death  a  cav- 
ity filled  with  a  brown  serous  fluid  was  found  in  the  anterior  and  ex- 
ternal part  of  the  right  corpus  striatum,  and  the  whole  of  the  left  pos- 
terior lobe'  was  reduced  to  a  yellowish  pulp,  and  was  studded  with 
purulent  foyers.  This  was  certainly  not  an  uncomplicated  case.  And 
thus  of  the  five  there  was  but  one  in  which  there  was  indubitably  no 
paralysis. 

The  optic  thalamus  is  another  common  seat  of  extravasation.  In 
such  a  case  the  observed  symptoms  are  especially  connected  with  the 
organs  of  the  special  senses.  Thus  there  are  double  vision,  dilatation 
or  convulsive  movements  of  the  pupil,  blindness,  and  anaesthesia  or 
hyperesthesia  of  the  paralyzed  parts  of  the  body.  As  in  lesions  of  the 
corpus  striatum,  the  paralysis  of  motion,  if  present  at  all,  is  on  the 
opposite  side  of  the  body,  and  is  usually  transient  in  character.  The 
hearing  and  smell  may  also  be  affected.  Luys2  has  collected  a  large 
number  of  cases  in  support  of  the  view  here  enunciated. 

The  researches  of  Virenque3  also  go  to  show  that  lesions  of  the 
optic  thalamus  are  accompanied  with  loss  of  sensibility  on  the  opposite 
side  of  the  body.  His  observations,  therefore,  are  entirely  confirm- 
atory of  those  of  Turck,4  who  in  four  very  carefully  recorded  cases 
found  hemi-anaesthesia  coexistent  with  lesion  of  the  optic  thalamus 
and  corpus  striatum  of  the  opposite  side. 

In  those  cases  of  cerebral  hemorrhage  limited  to  the  optic  thala- 
mus, paralysis  of  motion  when  it  exists  is  less  intense  than  when  the 
corpus  striatum  is  also  involved,  and  is  often  restricted  to  the  inferior 
limbs.     The  speech  is  rarely  involved. 

1  Op.  tit.,  tome  ii.,  p.  142  el  acq.  2  Op.  tit.,  p.  534  et  seq. 

3  "  De  la  perte  dc  la  scnsibilite  generale  et  sp6cialc  d'un  cote  du  corps  (hemianaesthe- 
siae)  et  de  ses  relations  avec  certaines  lesions  des  centres  opto-stries."     Paris,  1874. 

4  "  Ueber  die  Bcziehung  gewissen  Krankheitsherde  des  grossen  G^hirns  zur  Anaes- 
thesie."  Silzungsbcrichte  des  Kais.  Kon.  Academic  dcr  Wisscnschaften,  Band  xxxvi., 
1859. 


CEREBRAL   HEMORRHAGE. 


113 


Fig.  11. 


The  symptoms  just  detailed  are  more  the  result  of  lesions  affect- 
ing adjacent  regions  than  of  the  thalamus  itself.  The  sensory  division 
of  the  internal  capsule  and  the  optic  tract  are  the  parts  most  liable  to 
be  injured  from  haemorrhage  in  the  thalamus. 

The  intelligence  is  not  notably  lessened,  but  there  is  often  a 
marked  proclivity  to  the  supervention  of  hallucinations  of  the  special 
senses.  Luys1  has  very  thoroughly  worked  up  this  subject,'  and 
Ritti  has  recently  in  a  philosophical  essay  adduced  many  facts  and 
arguments  to  show  the  relations  of  lesions  of  the  optic  thalamus 
with  hallucinations.  In  thirty-two  cases  of  hallucinations,  mainly 
of  the  sight  and  hearing,  but  some- 
times of  all  the  senses,  post-mortem 
examinations  revealed  the  existence 
of  some  kind  of  lesion  of  the  optic 
thalami. 

It  sometimes  happens  that  an  ex- 
travasation, originating  in  either  the 
corpus  striatum  or  optic  thalamus, 
involves  both  these  ganglia  and  the 
intervening  part  of  the  internal  cap- 
sule. Hence  we  have,  as  the  most 
common  symptoms  of  ha?morrhage 
of  this  character,  loss  or  impairment 
of  the  power  of  motion,  disturbance 
of  sensibility,  dilatation  or  irregular 
movements  of  the  pupil,  aberrations 
of  vision  and  hearing,  etc. 

As  we  have  seen,  a  lesion  of  the 
posterior  half  of  the  internal  capsule 
of  one  side  produces  loss  of  the  power 
of  motion  and  of  sensibility  in  the 
opposite  side  of  the  body.  The  man- 
ner in  which  this  is  accomplished  will 
be  readily  understood  from  an  inspec- 
tion of  the  accompanying  diagram 
(Fig.  11),  in  which  a  indicates  the 
left  interna]  capsale  containing  both 

motor  and  sensory  fibres  ;  b  the  lift  half  "^  ^10  p()lis  Varolii  and  me- 
dulla oblongata  ;  c  the  left  lateral  half  of  the  spinal  cord ;  d  a  sensory 
nerve-fibre  decussating  Boon  after  its  entrance  into  the  cord;  e  a 
motor  nerve-fibre  decussating  at  the  lower  boundary  of  the  medulla 
oblongata  A  lesion  existing  at  ./'will  therefore  cause  paralysis  of 
motion  and  of  sensibility  at  <j,  on  the  r\'j}\\  side  of  the  body, 

1    Op.  ct  ],,r.  rit. 

*  "Tlii'uiir  piivsiologiquc  dc  l'hallucination."    Paris,  1874. 
9 


114  DISEASES  OF  THE  BRAIN. 

When  the  extravasation  beginning  in  the  left  optic  thalamus  or 
corpus  striatum  extends  to  the  fissure  of  Sylvius  so  as  to  involve  the 
posterior  part  of  the  third  frontal  convolution,  the  island  of  Reil, 
or  other  part  supplied  by  the  middle  cerebral  artery,  or  when  it 
originates  in  this  region,  aberrations  of  speech  occur.  These  are  in- 
dependent of  paralysis  of  the  tongue,  and  are  such  as  are  embraced 
under  the  term  aphasia.  This  subject  will  be  hereafter  more  fully 
considered. 

If  the  lesion  be  limited  to  the  anterior  two-thirds  of  the  posterior 
half  of  the  internal  capsule,  there  will  be  merely  paralysis  of  motion, 
although  there  may  be,  as  I  have  lately  had  occasion  to  know,  slight 
and  temporary  hemi-an:esthesia.  If,  however,  the  posterior  third  of 
the  posterior  half  of  the  internal  capsule  be  the  seat  of  the  haemor- 
rhage, there  wTill  be  well-marked  hemi-anaesthesia.  Of  course  there 
are  in  almost  all  cases  various  proportional  combinations  of  loss  of 
the  power  of  motion  and  of  sensibility  according  to  the  exact  posi- 
tion of  the  lesion  in  the  internal  capsule.  And  it  invariably  happens 
that  with  all  lesions  of  the  motor  tract  late  contractions  of  the  op- 
posed muscles  supervene. 

Haemorrhage  into  the  crus  cerebri  produces  hemiplegia  of  the 
opposite  side,  more  or  less  extensive,  according  to  the  size  of  the  clot, 
with  loss  of  sensibility.  The  third  pair  arises  in  part  from  the  crus, 
and  hence  may  be  paralyzed,  producing  ptosis  and  external  strabis- 
mus on  the  side  corresponding  to  the  seat  of  the  lesion,  and  conse- 
quently opposite  to  the  hemiplegia. 

When  the  pons  Varolii  is  affected,  the  crossed  paralysis  is  still 
more  marked.  The  limbs  are  paralyzed  on  the  opposite  side,  and 
the  face  in  whole  or  in  part  on  the  same  side  as  that  in  which  the 
haemorrhage  takes  place.  If  the  extravasation  is  in  the  mesial  line, 
both  sides  of  the  body  are  paralyzed.  According  to  Trousseau,1  how- 
ever, crossed  paralysis  is  not  always  due  to  a  lesion  of  the  pons,  as 
asserted  by  Gubler,2  and  as  supported  by  additional  cases  collected 
by  Luys.3  Trousseau  rests  his  opinion  on  one  case,  in  which  after 
death  very  extensive  lesions  of  the  brain  were  found,  but  none  involv- 
ing the  pons. 

Nevertheless  we  find  in  practice  that  when  an  extravasation  of 
blood  is  confined  to  one  side  of  the  pons,  and  is  not  extensive,  the 
face  is  paralyzed  on  the  corresponding  side.  The  facial  nerve  makes 
its  exit  from  the  side  of  the  medulla  oblongata ;  some  of  its  roots 
of  origin  can  be  traced  as  far  as  the  floor  of  the  fourth  ventricle, 
others  come  from  the  lower  part  of  the  medulla  oblongata,  and  others 

1  "  Lectures  on  Clinical  Medicine,"  Bazire's  translation,  Part  II.,  p.  333. 
a  "  Sur  l'hemiplegie  alterne,"  Gaz.  hebd.,  October,  1856,  and  "  Memoirc  sur  les  para- 
lysies  alternes,"  etc.,  Gaz.  Iiebd.,  1859. 
8  Op.  cit.,  p.  529  el  scq. 


CEREBRAL  HAEMORRHAGE. 


115 


Fig.  12. 


descend  from  the  upper  border  of  the  pons,  where  they  probably  decus- 
sate. Now,  a  lesion  existing  in  a  lateral  half  of  the  pons  will,  there- 
fore, produce  a  paralysis  of  the  corresponding  facial  nerve,  and  of  the 
opposite  spinal  nerves;  whereas,  if 
it  occur  above  the  point  of  decus- 
sation of  the  encephalic  fibres,  the 
paralysis  will  be  on  the  opposite 
side  for  all  parts  of  the  body. 
These  facts  are  shown  in  the  ac- 
companying diagram  (Fig.  12). 

It  is  obvious,  from  a  study  of 
this  diagram,  that  a  lesion  of  one 
lateral  half  of  the  pons  (at  I)  will 
cause  paralysis  of  motion  and  of 
sensibility  of  the  opposite  side  of 
the  body  generally,  and  of  the  cor- 
responding side  of  the  face  ;  and 
that  a  lesion  of  the  hemisphere 
(at  m)  will  produce  paralysis  of 
the  opposite  side  of  the  face  and 
the  body. 

It  is  true  that  it  is  not  definite- 
ly settled  by  histological  investiga- 
tion that  the  decussation  of  the 
ascending  roots  takes  place,  but 
pathology  is  just  as  capable  of 
determining  the  question  as  his- 
tology. Vulpian  '  asserts  that  the 
decussation  of  the  roots  of  the 
facial  occurs  in  the  mesial  line  of 
the  medulla  oblongata  at  the  junc- 
tion of  the  two  nuclei  of  origin  ; 

but,  if  this  were  the  case,  a  lesion  of  one  side  of  the  pons  would  n< 
Barily  he  followed  by  double  facial  paralysis,  a  sequence  which  does 
not  in  reality  ensue. 

From  the  contiguity  of  the  pons  to  the  medulla  oblongata,  an  ex- 
travasation of  blood  info  it  is  generally  accompanied  by  the  symptoms 
which  result  from  hemorrhage  into  this  latter  Organ,  though  they  are 
not  as  a  rule  so  strongly  marked. 

The  prinoipal  phenomena  indicating  the  medulla  oblongata  as  the 

seat  of  extravasation  are,  h.ssof  the  power  of  swallowing,  from  paraly- 
sis of  the  glossopharyngeal,  difficulty  >>f  protruding  the  tongue,  from 
paralysis  of  the  hypoglossal,  and  husldnesa  of  the  voice,  tumultuous 

1  "Ess-ai  sur  1'on^inc  dc  plusicurs  pairs  dc  ncrfs  cranious.     Thfcso  dc  Paris,"  1853, 
p.  32. 


a,  the  loft  hemisphere  ;  b,  right  half  of  pons:  c. 
right  half  of  medulla  oblongata;  d,  right  half  of 
spinal  cord ;  e,  right  facial  nerve :  /.  fibre  of 
origin  from  nucleus  in  medulla  oblon : 
descending  fibre  decussating  at  upper  border 
of  pons;  A,  ascending  fibre;  >'.  sensory  root  of 
spinal  nerve;  k,  motor  root  of  sensory  nerve; 
I,  lesion  in  pons;  m,  lesion  in  loft  hemisphere ; 
n,  paralyzed  part  supplied  by  facial;  o,  para- 
lyzed part  supplied  by  spinal  DOTS. 


116  DISEASES   OF   THE   BRAIN. 

action  of  the  heart,  dyspnoea  and  gastric  derangements,  from  paralysis 
of  the  pneumogastric  nerve.  There  is  in  addition  paralysis  of  one  or 
both  sides  of  the  body. 

An  extravasation  into  the  cortical  substance  of  the  cerebrum  is 
characterized  by  no  very  definite  aggregation  of  symptoms.  There 
may  be  delirium,  coma,  disorders  of  speech,  convulsions,  paralysis, 
contractions  or  rigidity  of  either  the  paralyzed  or  sound  limbs,  vomit- 
ing, derangement  of  respiration,  and  occasionally  anaesthesia  or  hyper- 
aesthesia.  Paralysis  when  present  is  upon  the  opposite  side  of  the 
body  from  that  of  the  lesion. 

When  the  extravasation  is  in  the  white  substance  of  the  cere- 
brum, not  included  in  the  direct  motor  and  sensory  tracts,  there  may 
be  no  marked  symptoms  of  diagnostic  value.  I  have  known  cases  in 
which  large  foyers  have  been  formed  with  no  other  symptoms  than 
intense  pain  in  the  head  and  persistent  vomiting.  But  when  blood 
is  extravasated  into  the  white  tissue  the  quantity  is  ordinarily  great, 
and  as  a  consequence  there  are  often  symptoms  present  which  are 
due  to  resultant  pressure  upon  other  portions  of  the  encephalic  mass. 
Thus  there  may  be  coma,  paralysis,  loss  of  sensibility,  stertorous  res- 
piration, and  other  phenomena  indicating  derangement  of  the  motor 
and  sensory  ganglia.  The  passage  of  the  extravasated  blood  into  the 
ventricles  almost  invariably  causes  contractions  or  convulsions  of  the 
muscles  of  the  opposite  side  of  the  body. 

The  researches  I  have  made  l  relative  to  the  functions  of  the  cere- 
bellum would  seem  to  show  that  its  office  is  not  materially  different 
from  that  of  the  cerebrum.  Still,  I  think  there  are  some  indications 
which,  although  not  perhaps  giving  us  the  right  to  form  a  definite 
conclusion,  are  yet  sufficiently  well  marked  to  enable  us  to  arrive  at  a 
probable  diagnosis  between  haemorrhagic  lesion  of  the  cerebrum  and 
that  of  the  cerebellum.  Thus,  vertigo  is  almost  an  invariable  accom- 
paniment of  the  cerebellar  extravasation  ;  vomiting  is  much  more  gen- 
erally met  with  than  when  the  cerebrum  is  affected  ;  hemiplegia  is  not 
so  common  ;  the  sensibility  is  never  disturbed  ;  and  the  pain  is  in  the 
back  of  the  head. 

Ferrier a  has  very  clearly  shown  that  irritation  of  the  cerebellum 
produces  nystagmus  and  defective  power  of  ocular  coordination.  But 
I  am  not  aware  that  these  phenomena  have  been  noticed  in  cases  of 
cerebellar  haemorrhage.  Hillairet,3  in  his  excellent  memoir,  does  not 
mention   them  as  features  of  the  affection.     He   distinguishes   two 

1  "  The  Physiology  and  Pathology  of  the  Cerebellum."  Quarterly  Journal  of  Psycho- 
logical Medicine,  April,  1869. 

9  "  Experimental  Researches  in  Cerebral  Physiology  and  Pathology."  "  West  Riding 
Lunatic  Asylum  Reports,"  vol.  Hi.,  1873,  p.  69,  elseq. 

3  "H6morrhagie  cer6belleuse,"  Annuaire  de  medecine  el  ckirurgie  pratiques,  1859,  p. 
39.     Also  Archives  de  medecine,  58. 


CEREBRAL   HEMORRHAGE.  117 

forms  of  this  lesion.  In  the  one,  the  onset  is  sudden,  and  death  soon 
follows ;  in  the  other,  the  course  of  the  affection  is  slow,  and  life  may 
he  prolonged  for  a  considerable  period.  In  this  latter,  vomiting  is  a 
prominent  feature.  Hemiplegia,  according  to  him,  is  always  crossed. 
Sensibility  remains  unaffected  till  near  the  close  of  the  disease  by 
death,  and  there  are  no  convulsions.  The  speech  is  not  often  affected. 
The  special  senses  he  did  not  find  notably  deranged,  except  in  the  last 
stage.     In  this  result  he  differs  with  several  writers  on  the  subject. 

Besides  a  number  of  cases,  some  of  which  are  referred  to  in  the 
memoirs  cited,  one  has  occurred  in  my  experience,  in  which  I  had  the 
opportunity  of  making  a  post-mortem  examination.1 

A  man  had  suffered  from  vertigo,  occasional  convulsions,  attacks 
of  nausea,  and  vomiting,  and  a  constant  and  violent  pain  affecting  the 
back  of  the  head.  The  symptoms  had  ensued  in  consequence  of  a  se- 
vere blow  which  he  had  received  on  the  back  of  the  head,  by  raising 
himself  too  soon  while  the  horse  he  was  riding  was  passing  under  a 
low  archway. 

When  this  man  attempted  to  walk,  he  reeled  and  staggered  as  if  he 
were  drunk.  The  upper  extremities  and  the  organs  of  speech  were 
not  affected  ;  he  had  the  entire  control  of  his  legs  when  lying  down, 
and  there  was  no  diminution  of  sensibility  anywhere.  At  last,  he  be- 
came paraplegic,  and  shortly  afterward  died  in  a  convulsion.  The 
post-mortem  examination  showed  the  existence  of  an  abscess  which 
had  obliterated  nearly  the  whole  of  the  left  lobe  of  the  cerebellum. 
The  other  parts  of  the  brain  were,  so  far  as  could  be  perceived,  per- 
fectly healthy. 

Besides  the  occurrence  of  local  secondary  lesions,  the  immediate  re- 
sults of  the  presence  of  a  foreign  body  in  the  cerebral  tissue,  there  are 
<>i  hers,  which  are  due  to  the  interruption  of  the  normal  brain-functions, 
which  hemorrhage  so  generally  induces.  Thus,  atrophy  of  the  cere- 
bral structure  may  result,  as  has  been  pointed  out  by  Cotarda  and  oth- 
er-, or  the  degeneration  may  extend  to  the  spinal  cord,  as  is  so  well 
shown  by  Bouchard.'  In  this  latter  event  the  process  does  not  begin 
till  about  the  end  of  the  fourth  or  fifth  month.  It  is  mainly  charac- 
terized by  the  supervention  of  permanent  contraction  of  certain  of  the 
paralyzed  muscles,  and  by  exaggerated  reflexes,  and  will  be  more 
appropriately  considered  under  another  head. 

Another  point  in  connection  with  cerebral  haemorrhage  requires 
further  elaboration.  It  is  well  known  thai  the  facial  paralysis  result- 
ing from  ordinary  cerebral  hemorrhage  is  less  extensive  and  less  thor- 
oughly marked  than  when  it  is  due  tO  disease  <>r  injury  of  the  trunk  of 

1  Op.  e&,  p.  -' 

9  "  titode  but  ('atrophia  partiellc  du  oerrean,"  Parte,  I 

degeneration!  tecondairei  de  li  moelle  epiniflre,"  Archive*  atn,  d 

1866.    Also  Hun's  translation,  American  Journal  of  J„ sanity,  isi;y. 


118  DISEASES  OF  THE  BRAIN. 

the  seventh  pair  or  to  lesion  of  the  pons  Varolii.  Thus  we  have  seen 
that,  in  the  former  affection,  the  orbicularis  palpebrarum  escapes  pa- 
ralysis,1 and  the  other  muscles  supplied  by  the  facial  nerve  are  usually 
not  so  profoundly  paralyzed  as  when  the  pons  or  the  nerve  is  the  seat 
of  the  disease. 

Many  explanations  have  been  offered  of  this  remarkable  circum- 
stance, but  the  one  given  by  Landry a  is  more  nearly  reconcilable 
with  the  anatomy  and  physiology  of .  the  parts  involved  than  any 
other. 

The  nucleus  of  the  facial  is  entirely  comparable  to  the  anterior 
cornua  of  the  cord.  It  constitutes  a  little  special  motor  nerve-centre 
which  possesses  a  certain  amount  of  autonomy.  It  is  through  this 
centre  that  the  muscles  of  the  face  are  directly  made  to  contract. 
The  encephalic  fibres  which  connect  it  with  the  brain  are  only  at  the 
service  of  the  psychical  department,  and  an  impulse  sent  through  them 
is  not  of  itself  capable  of  exciting  contraction  in  the  muscles  to  which 
the  facial  is  distributed.  But,  with  the  spinal  cord,  this  nucleus  pos- 
sesses reflex  excitability,  and,  as  is  the  case  in  diseases  of  the  brain 
in  which  the  anterior  columns  suppress  voluntary  movements  without 
destroying  the  reflex  manifestations  of  which  the  gray  substance  of  the 
cord  is  susceptible,  so  the  cerebral  lesion  leaves  to  the  nucleus  of  the 
facial  the  power  to  determine  reflex  contractions.  It  therefore  con- 
tinues to  be  excited  by  sensitive  excitations  which  reach  it  from  the 
periphery.  Thus,  in  facial  hemiplegia  of  cerebral  origin,  we  observe, 
from  time  to  time,  certain  movements  which  appear  to  be  voluntary 
because  the  provocative  sensitive  impression,  which  may  only  consist 
of  the  contact  of  air,  remains  unperceived.  Accordingly,  the  orbicularis 
palpebrarum  appears,  above  all  the  other  muscles,  to  preserve  its  mo- 
bility, for  its  movements  are  principally  excited  by  the  stimulus  of  the 
light,  which  the  lesion  of  the  cerebral  lobes  does  not  prevent  being 
reflected  to  the  nucleus  of  the  facial.  In  extensive  diseases  of  the 
pons,  however,  the  nucleus  of  the  facial,  situated  as  it  is,  in  immediate 
proximity  to  this  organ,  is  almost  always  compromised  with  it.  In 
such  a  case,  therefore,  both  reflex  excitability  and  voluntary  power  are 
destroyed,  and  the  paralysis  is  complete. 

Treatment.— The  means  of  treatment  in  cerebral  haemorrhage  are, 
first,  those  which  are  applicable  to  the  prodromatic  stage,  with  a  view 

1  Bazire,  in  his  translation  of  Trousseau's  "  Clinical  Lectures,"  calls  attention  to  the 
fact  that,  in  ordinary  cases  of  cerebral  hemorrhage,  the  patient,  though  able  to  close  the 
eye  of  the  affected  side,  cannot  do  so  without,  at  the  same  time,  closing  the  other,  a  fact 
which  shows  some  loss  of  power.  Since  my  notice  was  directed  to  this  circumstance,  I 
have  observed  that  the  patient  is  often  sensible  of  the  fact  that  the  eye  of  the  affected 
side  cannot  be  closed  as  strongly  or  as  rapidly  as  the  other  eye. 

5  Quoted  by  Poincare,  "Lecons  sur  la  physiologie  normale  et  pathologique  du  systeme 
nerveux,"  tome  deuxieme,  Paris,  1874,  p.  55. 


CEREBRAL  HAEMORRHAGE.  U9 

of  preventing  any  lesion  ;  second,  those  proper  during  the  seizure  ; 
and,  third,  those  which  are.  to  be  directed  against  the  consequences  of 
an  attack. 

It  often  happens  that  an  attack  may  be  prevented,  even  where  the 
threatenings  are  very  decided.  The  condition  of  the  brain  is  such  that 
the  indications  are  to  lessen  the  tension  of  the  blood  as  much  as  pos- 
sible. As  I  have  already  remarked,  under  the  head  of  cerebral  conges- 
tion, the  bromides  of  potassium  and  sodium  are  peculiarly  efficacious  in 
accomplishing  this  end.  Lately,  in  consequence  of  the  investigations 
of  Dr.  S.  Weir  Mitchell,  of  Philadelphia,  I  have  made  much  use  of  the 
bromide  of  lithium  in  cerebral  congestion  with  or  without  a  tendency 
to  haemorrhage,  and  have  reason  to  prefer  it  to  either  the  potassium  or 
sodium  salt.  One  feature  of  its  action,  which  renders  it  especially  use- 
ful in  such  cases  as  those  now  under  notice,  is  the  short  interval  which 
elapses  between  its  administration  and  the  effect.  I  am  very  sure  I 
have  given  it  successfully  in  several  cases  in  which  the  bromides  men- 
tioned would  not  have  acted  so  happily.  In  one  of  these,  a  gentleman 
from  the  South,  who  had  already  had  an  attack,  and  who  was  in  con- 
sequence hemiplegic,  was  relieved  of  his  vertigo,  headache,  numbness, 
and  thickness  of  speech,  by  one  dose  of  thirty  grains,  in  less  than  half 
an  hour.  The  bromide  of  calcium,  a  compound  to  which  I  have  recent- 
ly called  attention,1  is  still  more  eligible.  It  acts  more  rapidly  than 
any  of  the  other  bromides,  and  may  be  given  for  a  longer  period  with 
less  derangement  of  the  organism.  The  dose  is  from  fifteen  to  thirty 
grains,  or  even  more,  if  only  a  single  dose  is  to  be  administered.  The 
oxide  of  zinc  may  also  be  given  with  advantage. 

The  bowels,  if  costive,  should  be  opened  by  a  brisk  purgative  ;  the 
stomach,  if  overloaded,  should  be  emptied  by  an  emetic,  during  the 
action  of  which  warm  water  should  be  freely  drunk  so  as  to  obviate, 
as  far  as  possible,  all  straining  ;  muscular  exertion  should  be  avoided, 
the  head  should  be  kept  cool  and  well  elevated,  and  the  mind  in  a  state 
of  the  utmost  tranquillity. 

During  an  attack,  and  throughout  the  whole  period  of  reparation  of 
damages,  the  less  that  is  done  in  the  vast  majority  of  cases  the  better. 
The  question  of  the  propriety  of  bloodletting  will  generally  even  yet 
arise,  but  should  in  nearly  every  case  be  decided  in  the  negative.  I  say 
nearly,  for  I  know  of  but  one  possible  form  of  attack  in  which  it  can 
by  any  possibility  not  only  not  be  useful,  but  fail  to  do  harm  ;  and  that 
is  in  a  strong,  plethoric  person,  with  a  full,  bounding  pulse,  in  whom, 
from  the  gradual  development  of  the  symptoms,  we  have  reason  to  bus- 
peol  thai  the  h&morrhage  is  still  going  on.    In  such  a  case,  six  or  eight 

ounces  of  blood  may  be  taken  from  the  arm.      But,  in  the  case  of  cere- 
bral   haemorrhage,   attended   by   coma  and   the  ordinary  symptoms  of 

1  Note  relative  to  Lroniide  of  Calcium.     New  York  Medical  Journal,  December,  1871, 
p.  594. 


120  DISEASES  OF  THE  BRAIN. 

the  apoplectic  condition,  there  is  nothing  to  he  done  in  the  way  of 
medication  which  can  afford  the  slighest  prospect  of  relief.  It  is  true, 
a  patient  thus  situated  may  recover  if  his  attack  is  not  of  the  severest 
kind,  hut  it  is  not  through  any  medicines  we  give  him.  Correct  views 
relative  to  this  point  are  far  from  being  prevalent,  and  can  only  be  es- 
tablished by  regard  being  paid  to  the  morbid  anatomy  and  pathology 
of  the  subject. 

A  clot  in  the  brain  is,  to  all  intents  and  purposes,  a  foreign  body, 
and  both  it  and  the  walls  of  the  cavity  must  undergo  certain  fixed  and 
definite  changes.  In  order  that  these  changes  may  go  on  with  the 
utmost  possible  regularity  and  certainty,  all  the  powers  of  the  system 
are  requisite.  The  processes  are  not  morbid  ;  on  the  contrary,  they  are 
in  the  highest  degree  conservative.  To  take  blood  from  a  body  which 
is  striving  by  all  its  agencies  to  repair  an  injury,  is  to  deprive  it  of  a 
portion  of  its  strength  without  in  the  slightest  degree  accelerating  the 
actions  at  the  seat  of  the  lesion.  As  Trousseau l  remarks,  no  physician 
ever  thinks  of  bleeding  for  an  extravasation  of  blood  under  the  skin, 
for  he  knows  how  perfectly  absurd  such  a  practice  would  be  ;  and  yet, 
except  as  regards  location,  there  is  no  difference  between  it  and  the 
cerebral  clot.  A  prize-fighter,  for  instance,  receives  a  blow  in  the  face, 
which  ruptures  a  blood-vessel  and  gives  him  a  "black  eye."  He  has  an 
extravasation  of  blood  into  the  cellular  tissue.  What  would  be  thought 
of  the  physician  who  would  recommend  bloodletting  from  the  arm,  with 
a  view  of  causing  the  absorption  of  the  clot  ?  The  prize-fighter  has 
found  out  by  experience  that  he  can  open  the  skin  with  a  knife,  and 
let  the  blood  out.  The  practice  is  excellent,  and  would  be  admirable 
for  the  brain  also,  were  this  organ  of  no  more  vital  importance  than  the 
skin  of  the  face.  I  have  never  bled  a  patient  for  cerebral  haemorrhage 
since  1849,  and  I  am  very  sure  that  I  have  had  no  reason  to  regret  the 
abandonment  of  the  practice. 

It  is  a  common  practice  for  purgatives  to  be  given,  and  even  so 
conservative  a  practitioner  as  Dr.  J.  Hughlings  Jackson a  puts  "  two 
drops  of  croton-oil  on  the  tongue,"  why,  he  does  not  state,  and  cer- 
tainly the  practice  is  in  direct  antagonism  not  only  with  his  assertion 
that  "  the  chief  thing  is  to  keep  the  patient  quiet,"  but  with  the  gen- 
eral tenor  of  his  theory  of  treatment.  I  have  seen  great  annoyance 
and  an  aggravation  of  the  symptoms  from  the  indiscriminate  admin- 
istration of  croton-oil.  It  is  only,  in  my  opinion,  admissible  when 
there  is  obstinate  constipation,  and  when  after  three  or  four  days  the 
bowels  have  not  been  moved. 

And  then  as  regards  iodide  of  potassium.  There  seems  to  be  an 
idea  prevalent  that  this  substance  exerts  a  powerful  influence  in  caus- 

1  "  Lectures  on  Clinical  Medicine,"  Bazire's  translation,  Part  I.,  p.  10. 

2  Reynolds's  "System  of  Medicine,"  vol.  ii.,  article  "Apoplexy  and  Cerebral  Heemor- 
rhage,"  p.  541. 


CEREBRAL   HEMORRHAGE.  121 

ing  the  more  rapid  absorption  of  the  extravasatecl  blood,  and  hence  it 
is  frequently  administered  in  large  and  frequently-repeated  doses.  I 
have  often  seen  patients,  at  as  early  a  period  as  possible,  while  still  in 
a  state  of  profound  coma,  dosed  with  the  iodide  of  potassium  to  the 
extent  of  five  grains  every  hour,  with  the  object  of  causing  the  imme- 
diate absorption  of  the  extravasated  blood.  That  such  a  result  is  im- 
possible no  one  acquainted  with  the  morbid  anatomy  and  the  pathology 
of  the  subject  will  deny. 

In  fact,  there  is  nothing  to  be  done  beyond  keeping  the  patient  per- 
fectly quiet,  with  the  head  well  elevated,  and  in  a  room,  when  possible, 
with  a  temperature  of  about  60°  and  thoroughly  ventilated.  Indica- 
tions should  be  met  as  they  arise.  The  bowels,  if  not  moved  naturally 
every  day,  may  be  emptied  by  an  enema  of  warm  water  ;  the  urine,  if 
not  passed  by  the  patient,  should  be  drawn  off  by  the  catheter  ;  the 
strength,  if  feeble,  as  indicated  by  the  pulse,  should  be  kept  up  by  the 
cautious  use  of  stimulants  ;  and,  if  the  patient  is  restless  and  does  not 
sleep  well,  some  one  of  the  bromides  should  be  administered. 

Ergot  may,  on  theoretical  grounds,  be  recommended  in  those  cases 
in  which  we  have  reason  to  believe  that  the  ha3morrhage  is  still  going 
on  ;  but  I  have  no  personal  experience  of  its  power  in  such  instances. 
If  administered,  it  should  be  given  with  no  sparing  hand. 

The  food  should  be  of  the  most  nutritious  character,  so  as  to  be 
small  in  quantity,  and  should  be  taken  frequently,  day  and  night. 
Beef-tea,  or  the  extract  of  beef,  made  according  to  Liebig's  formula, 
supplies  every  indication. 

If  symptoms  of  inflammation  make  their  appearance,  cold  applica- 
tions may  be  made  to  the  scalp,  or  a  blister  may  be  applied  to  the 
nape  of  the  neck.  Blisters  or  mustard-plasters  to  the  wrist  or  ankles 
are  absurd. 

Nothing  should  be  done  for  the  relief  of  the  paralysis  till  all  signs 
of  irritation  of  the  brain  have  disappeared,  and  the  patient  begins  to 
feel  the  restraint  of  confinement,  and  to  make  efforts  to  move  his  par- 
alyzed limb*.  These  evidences  of  improvement  generally  begin  soon 
after  the  eighth  day.  In  about  two  weeks,  therefore,  it  will  be  proper, 
in  the  majority  of  cases,  to  take  active  measures  to  restore  the  power 
of  motion,  and  to  prevent  those  contractions  which  tend  to  make  a 
restoration  much  more  difficult,  The  agents  to  he  employed  are  pas- 
sive motion,  strychnia,  phosphorus,  and  electricity.  The  first  is  accom- 
plished by  flexing  and  extending  the  joints  of  the  affected  limbs,  by 
friction,  ami  by  kneading  the  muscles  with  the  fingers.  These  move- 
ments should  he  performed  everj  'lav  for  five  or  ten  minutes  at  a  time. 
The  patient  should  likewise  he  encouraged  t<>  move  the  limbs  by  his 

own  volition  as  often  as  possible  short  of  causing  fatigue.  Strychnia 
ghould  he  given  in  doses  of  (lie  one-twenty-fourth  of  a  grain  three 
times   a  day,   or,  preferably,  by  Buboutaneous   injection,    in   somewhat 


122  DISEASES  OF  TIIE  BRAIN. 

smaller  doses  once  a  day.  In  old  cases  of  hemiplegia,  the  effects  of 
strychnia  thus  administered  are  often  well  marked,  and  are  exhibited 
when  administration  by  the  stomach  has  failed  to  produce  a  beneficial 
result.  This  is  seen  in  the  following  brief  abstract  of  sixteen  cases 
which  will  serve  as  types  of  numerous  others  which  have  occurred  in 
my  private  practice  : 

Case  I. — H.  A.,  aged  fifty  ;  male  ;  right  hemiplegia.  Came  under 
treatment  January,  1865  ;  strychnia  ineffectual  by  the  stomach  ;  thir- 
teen injections,  of  from  one-thirty-second  to  one-twenty-fourth  grain  ; 
much  improved. 

Case  II. — J.  S.  ;  forty-two  ;  male  ;  left  hemiplegia.  February, 
1865  ;  thirteen  injections  ;  much  improved. 

Case  III.  —  S.  T.  ;  sixty  ;  female  ;  right  hemiplegia.  February, 
1865  ;  strychnia  ineffectual  by  the  stomach  ;  nine  injections  ;  much 
improved. 

Case  IV. — I.  S.  ;  sixty  ;  female  ;  right  hemiplegia.  April,  1865  ; 
five  injections  ;  much  improved. 

Case  V.; — M.  T.  ;  fifty-two  ;  male  ;  right  hemiplegia.  April,  1865  ; 
strychnia  ineffectual  by  the  stomach  ;  eleven  injections  ;  cured. 

Case  VI. — O.  S.  ;  sixty-three  ;  female  ;  left  hemiplegia.  April  30, 
1865  ;  secondary  contractions  ;  twenty-two  injections  ;  no  improve- 
ment. 

Case  VII. — B.  R.  ;  forty-seven  ;  male  ;  left  hemiplegia.  June  11, 
1865  ;  strychnia  ineffectual  by  the  stomach  ;  seven  injections  ;  much 
improved. 

Case  VIII.— R.  F.  ;  fifty  ;  male  ;  left  hemiplegia.  June  17, 1865  ; 
strychnia  ineffectual  by  the  stomach  ;  eight  injections  ;  cured. 

Case  IX. — T.  W.  ;  forty-eight ;  male  ;  left  hemiplegia.  Septem- 
ber 5,  1865  ;  eight  injections  ;  much  improved. 

Case  X. — T.  S.  ;  forty-nine  ;  male  ;  left  hemiplegia.  Septem- 
ber 7,  1865  ;  secondary  contractions  ;  five  injections  ;  no  improve- 
ment. 

Case  XI.— J.  J.  ;  fifty-seven  ;  male  ;  left  hemiplegia.  September 
11,  1865  ;  secondary  contractions  ;  no  improvement. 

Case  XII.— J.  W.  ;  fifty-two  ;  male  ;  right  hemiplegia,  affecting 
arm  only,  at  the  time  treatment  was  begun.  September  27,  1865  ; 
strychnia  ineffectual  internally  ;  six  injections  ;  cured. 

Case  XIII.— W.  M.  ;  forty-five  ;  male  ;  left  hemiplegia.  October 
19,  1865  ;  strychnia  ineffectual  internally  ;  seven  injections  ;  cured. 

Case  XIV.— S.  M.  ;  forty-one  ;  male  ;  right  hemiplegia.  June 
17,  1867  ;  arm  alone  affected  ;  strychnia  ineffectual  by  the  stomach  ; 
twenty  injections  ;  cured. 

Case  XV.— M.  C.  ;  forty-four  ;  male  ;  right  hemiplegia,  affecting 
tongue  and  face  only.  July  1,  1867  ;  ten  injections  ;  so  much  im- 
proved as  to  be  able  to  talk  with  fluency. 


CEREBRAL   HEMORRHAGE.  123 

Case  XVI.— C.  C.  ;  fifty  ;  male  ;  right  hemiplegia.  May  4, 1869  ; 
strychnia  ineffectual  by  the  stomach  ;  thirty-five  injections  ;  much  im- 
proved. 

Dr.  Charles  Hunter '  has  called  attention  to  the  advantages  to  be 
derived  from  the  hypodermic  use  of  strychnia  in  hemiplegia  ;  and  my 
former  clinical  assistant,  Dr.  R.  A.  Vance,2  has  adduced  several  cases 
to  the  same  effect.  Instances  in  support  of  the  views  above  set  forth 
occur  daily  in  my  private  practice,  and  at  the  New  York  State  Hos- 
pital for  Diseases  of  the  Xervous  System.  I  have  every  reason,  there- 
fore, to  be  convinced  of  the  good  results  to  be  derived  from  the 
practice. 

Phosphorus  administered  in  the  form  of  phosphide  of  zinc,  sepa- 
rately or  in  combination  with  the  extract  of  nux-vomica,  according  to 
the  formula  given  on  page  68,  is  also  a  useful  remedy. 

But  no  agent  is  so  valuable  in  hemiplegia  as  electricity,  and  amend- 
ment almost  invariably  follows  its  use,  even  in  old  cases,  in  which 
there  are  tonic  contractions.  If  the  case  is  seen  soon  after  the  seizure, 
the  induced  current  will  generally  be  sufficient  to  produce  contractions 
of  the  paralyzed  muscles.  The  poles,  terminated  by  wet  sponges,  should 
be  applied  to  the  skin  covering  the  muscles,  or  in  some  cases  to  the 
nerves.  The  current  should  be  strong  enough  to  cause  slight  pain,  or,' 
if  sensibility  is  lessened,  to  produce  contraction.  In  old  cases  attended 
with  atrophy  of  the  muscles,  and  diminished  or  abolished  electro-con- 
tractility, the  primary  current  may  be  necessary.  It  should  be  applied 
in  such  a  manner  as  to  be  interrupted,  for  contractions  are  only  caused 
when  the  circuit  is  closed  and  opened.  As  the  muscles  improve  in  size 
and  irritability,  the  induced  current  should  be  used.  Care  should  be 
taken  not  to  fatigue  the  patient,  or  to  cause  excessive  pain  by  employ- 
ing a  current  of  too  great  a  degree  of  intensity. 

As  regards  the  restoration  of  sensibility,  it  will  generally  be  found 
to  be  less  difficult  than  the  removal  of  the  motor  paralysis.  The  anes- 
thesia very  often  disappears  or  becomes  much  less  spontaneously,  and  it 
does  so  from  the  centre  to  the  periphery  ;  that  is,  if  there  be  anaesthesia 
of  the  leg,  the  sensibility  returns  in  the  upper  part  first,  and  subse- 
quently in  the  lower  part.  The  treatment  consists  mainly  in  the  use  of 
the  electric  wire-brush,  which  should  be  passed  gently  over  the  skin 
previously  madedry.  The  other  pole  consists  of  a  wet  sponge.  Hither 
the  Induced  or  primary  currenl  may  be  used.  If  the  latter,  however, 
be  employed,  the  wire-brush  should  constitute  the  positive  pole. 

The  recent  advances  in  brain  surgery  give  us  reason  to  hope  for 

success  by  operative  procedure  in  those  cases  in  which  the  clol  involves 

the  cortes  "i-  in  eases  of  meningeal  haemorrhage,  the  affection  next  to 

1  British  and  F<,ixi:t>i  Medico-Chirwrgioal  Reviewt  April,  is 6 8. 

*  Journal  of  Psychological  Medicine,  April,  1870.    TLc  first  thirteen  oases  died  In 

this  work  wviv  published  iii  Dr.  Vance's  paper, 


124  DISEASES   OF   THE   BRAIN. 

be  considered.  When  the  symptoms  clearly  indicate  the  cortex  as 
the  seat  of  the  extravasation  it  is  an  easy  task  to  determine  its  exact 
location  ;  and  if  the  situation  is  such  that  it  can  be  reached  by  trephin- 
ing, the  operation  is  entirely  justifiable  unless  there  are  strong  contra- 
indications. The  question  is,  however,  one  which  is  to  be  settled  for 
each  individual  case,  and  not  to  be  determined  abstractly. 


CHAPTER  IV. 

CEREBRAL  MENINGEAL  HEMORRHAGE. 

By  the  term  cerebral  meningeal  haemorrhage  is  to  be  understood — 
1.  An  extravasation  of  blood  between  the  cranium  and  the  dura  mater  ; 
or,  2.  An  extravasation  into  the  cavity  of  the  arachnoid  between  the 
two  layers  of  which  this  membrane  is  composed ;  or,  3.  An  extravasa- 
tion into  the  sub-arachnoideal  space  between  the  arachnoid  and  the  pia 
mater,  or  into  the  tissues  of  this  latter  membrane,  or  between  it  and  the 
brain.  There  are  thus — 1.  Extra-meningeal  haemorrhages  ;  2.  Intra- 
arachnoideal  haemorrhages  ;  and,  3.  Sub-arachnoideal  haemorrhages. 
The  first  are  almost  always  the  result  of  traumatic  cause,  involving 
injuries  of  the  cranium,  by  which  the  vessels  of  the  dura  mater  are 
wounded.  Extra-meningeal  haemorrhage  may  likewise  be  produced 
by  the  operation  of  trephining,  should  any  of  the  vessels  of  the  dura 
mater  be  divided.  It  is,  however,  beyond  doubt  that  this  species  may 
originate  independently  of  wounds  and  injuries. 

The  distinction  between  intra-  and  sub-arachnoideal  haemorrhages 
was  first  pointed  out  by  Pros,1  to  whom  we  are  also  indebted  for  much 
valuable  information  on  the  subject.  Of  one  hundred  and  seventy- 
two  cases  collected  by  Gintrac,3  five  were  extra-meningeal,  one  hun- 
dred and  nine  intra-arachnoideal,  and  thirty-four  sub-arachnoideal. 

Symptoms. — The  most  prominent  symptom  of  meningeal  haemor- 
rhage is  coma,  which  may  appear  suddenly,  or  be  preceded  by  premon- 
itory symptoms,  such  as  headache,  vertigo,  and  general  convulsions. 
The  stupor  is  usually  profound,  and  does  not  differ  from  that  ob- 
served in  the  severe  forms  of  cerebral  haemorrhage.  The  power  of 
motion  is  generally  lost  throughout  the  body,  and  consequently  there 
is  usually  no  hemiplegia.  The  reason  for  this  is,  that  the  haemorrhage 
is  so  extensive  as  to  press  upon  both  hemispheres.  Reflex  and  auto- 
matic movements  remain,  except  when  the  medulla  oblongata  is  in- 
volved, when  some  of  them  are  abolished.  If  the  extravasation  is  in 
this  latter  situation,  death  soon  takes  place  from  cessation  of  respira- 

1  "  Memoire  sur  les  deux  maladies  connues  sous  le  nom  d'apoplexie  meninges."    Me- 
moires  de  Pacademie  dc  medecine,  tome  xi.,  1845,  p.  18. 
8  Op.  ci(.,  tome  i.,  p.  732. 


CEREBRAL   MENINGEAL   HEMORRHAGE.  125 

tory  actions.  Anaesthesia  is  present  in  the  skin  of  those  parts  in  which 
the  power  of  motion  is  lost. 

In  ordinary  cases  the  patient  may  pass  out  of  the  comatose  condi- 
tion from  the  fact  of  the  brain  becoming  accustomed  to  the  pressure, 
and  he  then  may  be  able  to  speak,  and  to  move  his  limbs,  but  his  men- 
tal and  physical  faculties  are  greatly  enfeebled,  and  a  renewal  of  the 
haemorrhage  again  plunges  him  into  a  state  of  coma,  from  which  he 
may  again  emerge.  This  sequence  may  be  repeated  several  times,  until 
death  at  last  takes  place.  Before  this  termination  there  are  vomiting, 
incontinence  of  urine  and  fasces,  insensibility,  and  occasionally  general 
convulsions. 

In  a  case  reported  by  Dugast,1  a  woman  entered  the  Hopital  Neckar 
in  a  state  of  marked  prostration.  Her  intelligence  was  not  markedly 
impaired,  but,  though  she  understood  almost  every  thing  said  to  her,  she 
answered  only  by  monosyllables  often  unintelligible,  and  pronounced  in 
a  low  voice.  She  was  affected  with  paralysis  of  the  left  side  of  the 
face,  and  an  incomplete  paralysis  both  of  motion  and  sensibility  of 
the  right  side  of  the  rest  of  the  body. 

Four  days  afterward  she  was  in  a  state  of  complete  prostration,  the 
paralysis  was  general.  Up  to  this  time  the  intelligence  had  remained 
almost  intact.  She  died  that  day.  The  post-mortem  examination 
showed  the  existence  of  a  large  sub-arachnoid  extravasation  at  the 
base  of  the  brain.  On  the  inferior  surface  of  the  pons  the  blood  had 
become  consolidated  into  a  clot  which  pressed  upon  the  left  lobe.  On 
the  right  side  of  the  pons  the  blood  had  not  coagulated.  This  case  is 
interesting  as  bearing  upon  the  subject  of  cross-paralysis  already  con- 
sidered in  the  previous  chapter. 

It  has  sometimes  happened  that  meningeal  haemorrhage,  resulting 
from  an  injury  of  the  cranium,  has  not  caused  any  very  prominent 
symptoms  for  a  considerable  period  afterward.  A  teamster  was  struck 
on  the  head  by  a  club  in  the  hands  of  another  man,  was  stunned  for 
a  few  minutes,  then  recovered,  and  went  about  his  business  without 
complaining  of  his  head.  In  about  twelve  hours  afterward  coma  su- 
pervened, and  he  died  without  being  aroused.  A  case  is  reported 
by  Dr.  Gibson,1  in  which  a  still  longer  period  intervened.  A  man, 
sixty  years  of  age,  was  found  one  morning,  about  eight  o'clock, 
seated  as  it"  asleep  at  a  desk,  his  anus  crossed  before  him,  and  his 
head  resting  on  them.  It  was  discovered  thai  he  was  profoundly  in- 
sensible.  He  was  sent  to  the  hospital,  where  he  lay  oomatose,  breath- 
ing Btertorously,  and  paralyzed  on  the  whole  of  one  Bide.  At  the  end 
of  two  days  he  died.  On  post-mortem  examination  there  was  found 
fracture  of   the  left  side  of  the  cranium,  with  rupture  of  the  dura 

1  '•  Quelqaea  considerations  Bur  les  hemorrhagies  m6ning6ee  c6r6brales."    Thi 

Pari*,   1869. 

*  Edinburgh  MedioalJou/rnal,  September,  1870,  p.  199. 


126  DISEASES  OF  THE  BRAIN. 

mater  and  middle  meningeal  artery,  from  which  latter,  extensive 
hemorrhage  had  taken  place.  It  was  ascertained  that,  five  days  be- 
fore, he  had  fallen  down  a  stone  staircase,  was  stunned  for  a  few 
minutes,  but  had  soon  recovered  his  senses.  Doubtless  during  the 
whole  of  the  intervening  period  the  bleeding  from  the  ruptured  ves- 
sel had  been  going  on. 

Prus,  in  the  memoir  cited,  attempts  to  draw  a  symptomatological 
distinction  between  sub-arachnoideal  and  intra-arachnoideal  haemor- 
rhage. Thus  for  him  headache,  dryness  of  the  tongue,  fever  and  de- 
lirium, are  indications  of  intra-arachnoideal  haemorrhage.  Somnolence 
and  coma  are  common  to  both  forms,  but,  when  they  are  conjoined 
with  the  phenomena  mentioned,  intra-arachnoideal  haemorrhage  is  to 
be  diagnosticated.  But  most  authors  doubt  if  the  discrimination  can 
in  reality  be  made  during  life.  Valleix '  declares  that  the  difference 
is  of  greater  anatomical  than  symptomatological  importance,  and 
Durand-Fardel4  admits  that  it  is  difficult  to  present  a  characteristic 
view  of  the  course  and  phenomena  of  sub-arachnoideal  haemorrhage. 
I  must  confess  that  I  see  no  greater  anatomical  reason  for  any  differ- 
ence in  the  symptoms  of  the  two  forms  of  meningeal  haemorrhage 
than  there  is  for  a  difference  between  inflammation  of  the  pia  mater 
and  inflammation  of  the  arachnoid.  Neither  are  there  any  char- 
acteristic symptoms  which  would  serve  to  distinguish  haemorrhage  of 
the  dura  mater  from  either  of  the  other  forms. 

Causes. — Among  the  predisposing  causes  of  meningeal  haemor- 
rhage age  occupies  the  first  place.  It  is  more  frequently  met  with 
in  young  infants  and  in  old  persons  than  in  those  of  middle  age. 
Legendre,8  in  two  hundred  and  forty-eight  cases  occurring  in  infants, 
and  in  which  post-mortem  examinations  were  made,  found  no  instance 
of  the  child  being  over  three  years  of  age.  Between  one  and  two 
years  would  appear  from  his  researches  to  be  the  period  in  which  chil- 
dren are  most  liable  to  the  supervention  of  meningeal  haemorrhage. 

But  Gintrac's  *  cases  are  of  different  import  as  regards  this  point, 
for  of  one  hundred  and  sixty-five  in  which  the  age  was  noted,  only 
ten  were  under  ten  years  of  age,  while  thirty-seven  were  between  the 
ages  of  thirty  and  forty,  sixty-seven  were  between  fifty-one  and  eighty, 
and  two  of  eighty-seven  and  eighty-eight  years  respectively. 

Meningeal  haemorrhage  is  often  produced  by  injuries  of  the  skull, 
and  results  from  sudden  rupture  of  a  healthy  artery  or  vein.  It  may 
follow  blows  on  the  head,  falls,  or  injuries  with  instruments  which 
perforate  the  cranium,  and  may  or  may  not  be  associated  with  fract- 
ures of  the  bones. 

1  "Guide  dc  m6decine  practicien,"  tome  ii.,  Paris,  1866,  p.  4. 

2  Op.  cit.,  p.  173. 

3  "  Rechcrches  sur  quelques  maladies  de  1'enfance."     Paris,  1846,  p.  113  et  seq. 

4  Op.  cit.,  p.  733. 


CEREBRAL  MENINGEAL  HEMORRHAGE.  127 

Extreme  heat  acting  upon  the  head,  venereal  excesses,  severe  mus- 
cular efforts,  excessive  mental  exertion,  amenrrohoea,  overfeeding,  and 
constipation  of  the  bowels,  have  been  cited  as  exciting  causes.  The 
larger  vessels,  or  the  capillaries,  may  give  way  from  being  diseased,  and 
consequently  unable  to  resist  the  ordinary  tension  of  the  blood.  Such 
a  condition  may  be  the  result  of  the  long-continued  excessive  use  of 
alcoholic  liquors,  or  may  be  due  to  hepatic  disease. 

Prognosis. — The  ordinary  termination  of  meningeal  haemorrhage  is 
death.  Of  thirty-one  cases  in  old  persons,  cited  by  Durand-Fardel, 
death  occurred  in  twenty-six  before  the  end  of  the  fifth  day,  in  one  it 
took  place  on  the  seventh  day,  in  two  on  the  fifteenth,  and  in  two  in 
from  twenty  to  twenty-five  days.  Legendre,  in  infants,  ascertained  the 
duration  to  be  from  eight  to  twelve  days.  Prus  found  death  to  ensue  in 
cases  of  sub-arachnoideal  haemorrhage  before  the  end  of  the  eighteenth 
day,  but  in  instances  of  the  intra-arachnoideal  form  life  was  sometimes 
prolonged  for  over  a  month. 

But  recovery  has  occasionally  taken  place  through  the  formation  of 
false  membranes  in  such  a  manner  as  to  circumscribe  the  extravasation, 
and  thus  to  conduce  to  the  absorption  of  its  fluid  portion,  and  Legendre 
has  described  a  process  occurring  in  children  by  which  the  sanguineous 
cyst  is  transformed  into  one  containing  serum,  thus  producing  a  species 
of  hydrocephalus.  Such  terminations  are,  however,  so  very  rare  as  to 
mitigate  but  to  a  very  slight  degree  the  gravity  of  the  prognosis. 

Diagnosis. — The  diagnosis  of  meningeal  haemorrhage  is  a  matter  of 
much  difficulty.  Still,  there  are  certain  characteristics  which  aid  us 
somewhat  in  arriving  at  a  correct  opinion.  Thus,  from  cerebral  haemor- 
rhage, it  may  usually  be  distinguished  by  the  fact  that  the  coma,  when  it 
exists,  comes  on  gradually,  that  the  headache  is  a  much  more  prominent 
symptom,  that  there  is  not  often  hemiplegia — the  paralysis  amounting 
to  a  general  resolution — and  above  all,  by  the  remissions  which  so  fre- 
quently mark  its  course.  Durand-Fardel '  declares  that  when  the 
coma  and  general  abolition  of  the  faculties  indicate  the  existence  of 
strong  cerebral  pressure  not  accompanied  by  paralysis,  properly  so 
called,  or  only  by  incomplete  paralysis,  perhaps  more  strongly  marked 
on  one  side  than  on  the  other,  we  may  suspect  the  presence  of  menin- 
geal haemorrhage  ;  that  a  cerebral  hemorrhage,  or  an  acute  softening 
sufficiently  extensive  to  produce  such  pronounced  symptoms  of  com- 
pression, is  always  accompanied  by  complete  paralysis  involving  a 
lateral  half  of  the  body,  and  that  the  full  development  of  the  phe- 
nomena is  ordinarily  preceded  by  violent  headache. 

From  cerebral  congestion  the  diagnosis  must  be  occasionally  al- 
most if  not  altogether  impossible,  and  the  same  is  true  of  cerebral 
Softening.       The    remissions   when    proent   in   meningeal    hamuli! 

will  afford  important  assistance  in  establishing  the  existence  of  the 

1  Op.  tit.,  p.  108. 


128  DISEASES   OF   THE   BRAIN. 

disease,  but  when  they  are  absent  the  difficulties  in  the  way  of  an  ex- 
act discrimination  may  be  insurmountable. 

Morbid  Anatomy  and  Pathology. — An  extravasation  of  blood  be- 
tween the  cranium  and  the  dura  mater,  extra-meningeal  haemorrhage, 
is,  as  nas  already  been  said,  almost  invariably  the  result  of  traumatic 
cause.  Gintrac,1  however,  with  his  usual  industry,  has  collected  five  cases 
in  which  it  appeared  to  be  idiopathic.  The  first  of  these  he  quotes 
from  Dr.  J.  H.  Wythes,a  of  Port  Carbon,  Pennsylvania,  but  he  omits  to 
state  that  the  child  had  been  playing  oh  the  door-step,  and  that  a  pain 
in  its  ankle  was  supposed  by  the  parents  to  have  been  due  to  a  sprain. 
It  is  probable,  therefore,  that  the  child  fell  and  struck  its  head.  The 
next  morning  it  was  found  dead  in  bed.  On  post-mortem  examination, 
an  extravasation  of  blood,  amounting  to  about  half  an  ounce,  was 
found  between  the  skull  and  dura  mater,  on  the  upper  surface. 

In  the  other  cases  the  blood  appears  to  have  been  effused  during 
extreme  congestion  of  the  meningeal  vessels,  one  or  more  of  the  latter 
having  given  way  under  the  excessive  tension  to  which  they  were  sub- 
jected. In  one  quoted  from  Abercrombie,  there  were  numerous  clots 
scattered  over  the  interior  surface  of  the  dura  mater,  and  which  seemed 
to  have  come  from  the  Pacchionian  bodies.  These  elevations  were 
very  vascular,  being  gorged  with  blood. 

The  anatomical  characteristics  of  intra-  and  sub-arachnoideal  haem- 
orrhages have  been  very  thoroughly  given  by  Prus.3  In  the  former 
the  blood  is  extravasated  by  exhalation,  that  is,  there  is  no  visible 
rupture  of  blood-vessels,  and,  if  life  be  prolonged  to  the  fourth  or  fifth 
day,  a  false  membrane  is  formed  by  which  the  clot  is  retained  in  appo- 
sition with  either  the  parietal  or  visceral  layer  of  the  arachnoid.  This 
membrane  eventually  becomes  organized  by  the  formation  of  vessels  in 
it,  and  may,  therefore,  be  the  source  of  another  haemorrhage;  for,  as 
Charcot  and  Vulpian  *  have  shown,  these  vessels  are  numerous,  large, 
possessed  of  very  thin  walls,  and  are,  therefore,  in  a  favorable  condi- 
tion for  giving  way  under  the  tension  of  the  blood. 

Brudet5  previous  to  Prus  had  described  the  false  membranes 
which  play  so  important  a  part  in  intra-meningeal  haemorrhage,  and 
bad  pointed  out  their  resemblance  to  the  arachnoid  and  their  liability 
to  be  the  source  of  other  haemorrhages,  and  at  about  the  period  of 
Prus's  publication  Mr.  Prescott  Hewett8  called  attention  to  extrava- 
sations attached   to  the  free  surface  of  the  arachnoid,  and  kept  in 

1  Op.  cit.,  tome  i.,  p.  646. 

2  "  Three  Cases  of  Infantile  Apoplexy."  North  American  Medico- Chirurgical  Re- 
view, January,  1858,  p.  "70. 

3  Op.  ct  loc.  cit. 

4  Gazette  hcbdomadaire,  1860,  pp.  728,  789,  821. 

5  "  Memoire  sur  l'hemorrhagie  des  meninges."  Journal  dcs  connaissances  m'cdico- 
chirurfjicales,  1839. 

c  Mcdico-Vhirurgical  Transactions,  vol.  xxviii.,  1845. 


CEREBRAL   MENINGEAL   HAEMORRHAGE.  129 

position  by  a  false  membrane  not  distinguishable  by  the  naked  eye 
from  a  true  serous  membrane. 

The  clot  may  be  extensive,  covering  nearly  the  whole  surface  of 
a  hemisphere.  The  vessels  which  have  given  way,  and  have  thus 
produced  an  intra-arachnoideal  haemorrhage,  are  usually  found  in  an 
atheromatous  condition,  and  the  vessels  of  the  neo-membranes  are 
especially  liable  to  be  thus  disease'!. 

Dr.  Sutherland1  in  a  very  interesting  memoir  gives  the  details  of 
ten  cases  of  arachnoid  cysts  occurring  in  the  insane :  "  On  removing  the 
skull-cap  and  dura  mater,  instead  of  the  convolutions  of  the  brain,  with 
its  vascular  pia  mater  meeting  the  eye,  there  appears  a  reddish,  pulpy, 
fluctuating  swelling  on  the  surface  of  the  brain,  having  such  a  uniform 
appearance  that  the  outline  of  the  convolutions  beneath  it  is  invisible. 
On  attempting  to  strip  off  the  cyst  from  the  surface  of  the  brain  it  is 
usually  found  adhering  to  the  visceral  arachnoid  along  the  centre  of 
the  longitudinal  fissure  ;  it  is  easily  separated  from  the  convolutions 
on  either  side  ;  but  if  large  enough  to  embrace  the  entire  hemisphere 
is  found  again  to  be  adherent  below,  but  in  this  situation  usually  to  the 
parietal  layer  of  the  arachnoid  membrane." 

Of  the  ten  cases  reported  by  Dr.  Sutherland,  four  were  in  all  proba- 
bility due  to  injury  of  the  head.  In  five  the  mental  aberration  was 
organic  dementia,  in  three  general  paralysis,  and  in  two  idiocy  and  im- 
becility. 

In  sub-arachnoideal  hemorrhages  the  blood  is,  as  we  have  seen,  ex- 
travasatcd  into  the  space  between  the  arachnoid  and  the  pia  mater,  and 
is  often  entangled  in  the  meshes  of  this  latter  membrane.  As  the 
blood  when  extravesated  is  mingled  to  a  greater  or  less  extent  with  the 
cerebro-spinal  fluid,  it  often  remains  liquid.  The  quantity  thrown  out 
is  frequently  very  large,  amounting  in  some  cases  to  apparently  as 
much  as  sixteen  or  even  twenty  ounces.  These  figures  must,  however, 
be  taken  with  some  allowance  for  the  amount  of  cerebro-spinal  fluid 
with  which  the  blood  is  combined. 

Tic  anai  >mical  relations  are  such  as  to  admit  of  sub-arachnoideal 
being  very  extensively  distributed  throughout  the  cranio- 
vertebral  cavity.     In  one  case  in  which  I  made  a  post-mortem  exam- 
inatioii,  it  occupied  the  whole  base  of   the    skull,  and,  in   a   case   cited 
by  Prus,  the  whole  b;:  cranium  was   filled  with  blood,  all  the 

ventricles   were  in  the  same  condition,  and  even  the  sub-arachnoid 
cavity  of  the  spinal  cord  was  invaded. 

New  membranes  are  never  met  with  in  this  form  of  meningeal  haem- 
orrhage.    Atheroma  of  the  arteries,  especially  of  those  at  the  ba 
the  cranium,  is  the  disease  which  is  ordinarilj  the  immediate  cause  of 
the  extravas  ition,  and  the  torn  vessel  can  generally  be  discovered  with- 

1  "Arachnoid  Cysts."    "West   Riding  Lunatic  Asylum   Medical   Reports,"  vol.  i., 
1871,  p.  218. 
10 


130  DISEASES   OF   THE   BRAIN. 

out  difficulty.  Aneurisms  of  the  basilar,  the  internal  carotid,  or  other 
arteries  of  the  base  of  the  brain,  have  by  their  rupture  been  the  cause 
of  sub-arachnoideal  haemorrhage. 

Treatment. — There  is  nothing  to  add  under  this  head  to  the  re- 
marks already  made  relative  to  the  management  of  cases  of  cere- 
bral hamiorrhage,  except  in  those  cases  where  the  symptoms  show 
that  the  clot  is  confined  to  a  small  area.  In  such  instances  tre- 
phining and  the  subsequent  removal  of  the  clot  may  be  successfully 
accomplished. 

PACHYMEOTNGITIS   AND    HEMATOMA    OF   THE    DURA   MATER. 

A  peculiar  form  of  meningeal  haemorrhage,  called  hasmatoma,  is 
met  with  under  the  dura  mater.  The  blood  is  not  diffused,  but  is 
collected  in  sacs  which  are  formed  of  false  membranes,  the  result  of 
chronic  inflammation  of  the  dura  mater ;  or  pachymeningitis  as  it 
has  been  designated  by  Virchow.  These  capsules  are  flattened 
ovals  in  shape,  are  three  or  four  inches  in  diameter,  and  half  an 
inch  thick.  They  are  usually  situated  at  the  vertex,  and  involve  both 
hemispheres.  When  this  is  the  case,  the  paralysis  which  results  is 
bilateral. 

Symptoms. — The  initial  symptoms  of  hasmatoma  of  the  dura  mater 
are  the  results  of  chronic  inflammation,  and  are  slow  in  their  progress. 
In  many  respects  they  resemble  those  indicative  of  softening,  and  con- 
sist of  weakness  of  intellect,  vertigo,  a  dull,  circumscribed,  persistent 
pain,  and  more  or  less  tendency  to  stupor.  The  power  of  motion  is 
generally  diminished  on  both  sides  of  the  body,  though  occasionally 
there  is  hemiparesis.  Paralysis  is  scarcely  ever  complete.  Contrac- 
tions of  the  limbs  and  twitching  of  the  muscles,  especially  of  those  of 
the  face,  have  occasionally  been  observed.  Gradually,  through  a  pe- 
riod extending  over  several  months,  the  stupor  increases,  and  finally 
the  patient  becomes  apoplectic.  During  the  whole  course  of  the  dis- 
ease the  pupils  are  strongly  contracted.  The  patient  dies  comatose 
and  frequently  convulsed. 

Causes. — Early  and  old  age  are  both  predisposing  causes,  the  dis- 
ease being  met  with  mainly  in  children  and  very  old  persons.  It  is 
frequently  seen  in  the  insane,  and  may  probably  result  from  rheu- 
matism, the  excessive  use  of  alcoholic  liquors,  and  fevers.  The  cause 
is  sometimes  to  be  found  in  wounds  or  injuries  of  the  skull. 

Diagnosis. — It  is  doubtful  if  hasmatoma  of  the  dura  mater  can  be 
definitely  recognized  either  in  the  stage  of  inflammation  or  that  of  haem- 
orrhage. Legendre1  states  that,  in  children,  the  most  important  diag- 
nostic mark  is  the  permanent  contraction  of  the  hands  and  feet,  which 
is  so  generally  present ;  but  this  symptom  is  certainly  met  with  in  other 

1  "  Rccherches  sur  quelques  maladies  de  l'enfance,"  Paris,  1846. 


CEREBRAL  MENINGEAL   HEMORRHAGE.  131 

cerebral  disorders,  and  may  even  result  from  reflex  irritations.  The 
diagnosis  is  rendered  still  more  difficult  by  the  fact  that  the  disease 
under  consideration  is  often  associated  with  other  cerebral  disorders 
which  mask  or  modify  its  symptoms.  The  absence  of  fever,  the  con- 
traction of  the  pupils,  the  slowness  and  irregularity  of  the  pulse,  the 
facts  that  there  are  no  vomitings  and  no  general  convulsions,  that  the 
nerves  distributed  to  the  several  parts  of  the  face  are  not  paralyzed, 
that  there  are  constant  and  very  severe  headache  and  a  gradually  in- 
creasing tendency  to  stupor,  are,  according  to  Jaccoud,1  sufficient  to 
indicate  the  presence  of  hcematoma  of  the  dura  mater.  I  am  of  the 
opinion  that  they  only  enable  us  to  give  a  guess  which  has  some  basis 
in  probability,  for  I  have  several  times  witnessed  exactly  such  a  condi- 
tion as  that  described,  and  after  death  found  other  morbid  conditions 
than  hematoma. 

Prognosis. — This  is  unfavorable,  death  resulting  sooner  or  later, 
according  to  the  extent  of  the  disease  and  the  natural  powers  of  the 
patient. 

Morbid  Anatomy  and  Pathology. — The  first  stage  of  hematoma 
of  the  dura  mater  is  characterized  by  the  formation  of  the  false 
membranes,  to  which  allusion  has  already  been  made.  These  mem- 
branes are  found  on  the  intei'nal  surface  of  the  dura  mater,  and  are 
reticulated,  presenting  somewhat  the  appearance  of  spiders'  webs. 
They  generally  have  their  seat  near  the  sagittal  suture,  and  extend 
to  both  hemispheres,  being  only  separated  from  them  by  the  arach- 
noid and  pia  mater.  Virchow,  who  has  studied  their  formation  with 
greater  care  than  any  other  observer,  has  found  more  than  twenty 
layers  of  them,  one  on  top  of  the  other,  and  traversed  by  numerous 
blood-vessels. 

Owing  to  this  great  vascularity,  to  the  extreme  tenuity  of  the  ves- 
sels, and  to  the  absence  of  any  perivascular  support,  haemorrhage  is 
liable  to  occur,  and  the  several  lamella-  thus  constitute  a  sac  into  which 
the  blood  may  be  poured.  This,  pressing  upon  the  cerebrum  below, 
and  constantly  being  enlarged  by  subsequent  haemorrhages,  gives 
ri.M'  to  the  symptoms  observed  during  life.  The  vessels  may  be  more 
liable  to  rupture  from  the  existence  of  atheromatous  degeneration 
of  their  CO 

Anatomically  and  pathologically  haematoma  of  the  dura  mater 
differs  from  intra- arachnoideal  hemorrhage  in  the  facts  that  the  ex« 
travasation  is  between  the  dura  mater  and  parietal  layer  of  the  arach- 
noid, and  that  the  formation  of  the  membrane  precedes  thehaBmorrl 
Those  authors  who  regard  the  arachnoid  as  consisting  of  but  a  single 
layer,  and  who  consequently  do  nol  admil  the  existence  of  intra- 
arachnoideal  haemorrhage,  musl  consequently  oonoede  that  there  are 
two  kinds  of  extra-araohnoideal  haemorrhage,  one  in  which  the  mem- 
'•Traite*  tlr  pathologic  Interne,"  tome  i.,  Paris,  1870. 


132  DISEASES   OF   THE   BRAIN. 

brane  forms  subsequently  to  the  appearance  of  the  extravasation,  and 
the  other  in  which  the  haemorrhage  is  the  direct  consequence  of  the 
formation  of  the  membrane. 

Others  again,  as,  for  example,  Gintrac  and  Durand-Fardel,  evi- 
dently regard  what  they  describe  as  intra-arachnoideal  haemorrhage  as 
identical  with  haeniatonia  of  the  dura  mater  ;  and  it  is  quite  certain 
that  many  of  the  cases  adduced  by  Gintrac  as  examples  of  intra- 
arachnoideal  haemorrhage  are  in  reality  instances  of  pachymeningitis 
with  subsequent  sanguineous  extravasation. 

The  difficulties  in  the  way  of  a  complete  understanding  of  the 
subject  are  greatly  lessened  by  remembering  the  distinction  pointed 
out  above,  that  hajmatoma  of  the  dura  mater  is  a  secondary  affec- 
tion, the  direct  result  of  inflammation  and  the  formation  of  false 
membranes  ;  while  in  intra-arachnoideal  haemorrhage  the  membrane 
is  derived  from  the  extravasated  blood,  which  is  the  first  step  in  the 
morbid  process. 

The  size  of  the  cysts  is  subject  to  much  variation,  the  quantity 
of  blood  ranging  from  one  or  two  to  sixteen  or  even  more  ounces. 
By  the  pressure  which  they  exert  upon  the  brain,  the  convolutions 
are  flattened,  and  even  softening  of  the  cerebral  tissue  may  be  pro- 
duced. 

Treatment. — This  requires  no  amplification  at  my  hands,  as  I  do 
not  believe  in  the  efficacy  of  any  means  for  curing  the  affection.  All 
that  can  be  done  is  to  palliate  the  more  violent  symptoms,  such  as 
the  headache  and  feebleness  of  mind  and  body,  by  anodynes  and 
stimulants,  and  of  these,  morphia  administered  hypodermically,  and 
alcohol  in  some  one  or  other  of  its  numerous  forms,  are  to  be  pre- 
ferred.    Bloodletting  and  blistering  are  worse  than  useless. 


CHAPTER  V. 


PARTIAL   CEREBRAL  ANEMIA    FROM  OBLITERATION  OF  CEREBRAL  BLOOD- 
VESSELS (ISCHEMIA). 

Obliteration  of  cerebral  blood-vessels  may  take  place— 

1.  By  thrombosis  of  the  arteries. 

2.  By  embolism  of  the  arteries. 

3.  By  thrombosis  of  the  veins  or  sinuses. 

4.  By  embolism  or  thrombosis  of  the  capillaries. 

I. THROMBOSIS    OF    CEREBRAL    ARTERIES. 

By  cerebral  arterial  thrombosis  is  understood  a  condition  in  which 
an  artery  of  the  brain  undergoes  narrowing  of  its  calibre  by  the  depo- 


PARTIAL   CEREBRAL   ANAEMIA,   ETC.  133 

sition  of  fibrin e  from  the  blood  on  its  internal  surface.     The  clot  thus 
formed  is  called  a  thrombus. 

Symptoms. — The  phenomena  observed  in  consequence  of  the  forma- 
tion of  a  thrombus  in  a  cerebral  artery  are  gradual  in  their  develop- 
ment, and  are  often  interrupted  by  stages  of  apparent  improvement. 
Headache,  as  in  so  many  other  affections  of  the  brain,  is  a  promi- 
nent symptom  and  is  almost  constantly  present.  It  is  not  usually 
diffused  over  the  whole  head,  but  occupies  a  place  having  a  close  rela- 
tion in  situation  with  the  seat  of  the  disease.  It  is  rarely  of  a  very 
aggravated  character,  and  is  remarkable  rather  for  its  persistency 
than  its  severity.  In  several  cases  which  have  come  under  my  notice, 
the  pupil  of  the  eye  of  the  affected  side  was  dilated  from  the  first, 
and  there  were  ptosis  and  strabismus,  showing  that  the  third  nerve 
was  involved. 

At  a  very  early  period  in  the  progress  of  the  disease  it  is  not  un- 
common to  meet  with  marked  difficulties  in  the  faculty  of  speech,  and 
these  not  only  relate  to  the  articulation,  but  to  the  memory  of  words. 
As  regards  the  first-mentioned  form,  there  may  be  restraint  in  the 
movements  of  the  tongue,  the  lips,  or  both,  or  there  may  be  a  loss  of 
coordinating  power  in  the  muscles  concerned  in  speech  without  any 
actual  paralysis.  Special  inconvenience  is,  therefore,  experienced  when 
attempts  are  made  to  pronounce  words  in  which  the  labial  and  lingual 
letters  are  prominent.  The  gutturals  in  such  cases  are  enunciated 
without  difficulty.  In  the  other  form  in  which  the  memory  of  words  is 
impaired,  the  patient  is  constantly  at  a  loss  for  language  with  which  to 
express  his  i<leas;  and,  though  the  proper  words  may  be  supplied  to 
him,  he  almost  immediately  forgets  them  again.  The  full  considera- 
tion of  this  interesting  subject  will  be  found  under  the  head  of  aphasia. 

Vertigo,  though  generally  present,  is  not  usually  severe,  at  least  in 
the  early  stages. 

The  incipient  symptoms  of  paralysis  soon  make  their  appearance 

in  the  majority  of  cases,  and,  though  there  is  a  gradual  advance  in  the 

loss  of  power,  there  are  periods  of  almost  entire  remission.     Thus  the 

leg,  or  the  arm,  or  the  face,  may  be  the  original  seat  of  the  paralysis, 

and  eventually  the  whole  of  one  side  be  involved.     In  a  case  of  prob- 

thrombosis  in  a  gentleman  now  under  my  charge,  the  paralysis 

was  at  first  limited  to  the  muscles  supplied  by  the  ulnar  nerve  and 

those  concerned  in  deglutition.     For  oik-  period  of  five  days  after  I 

first  saw  him,  there  was  an  entire  remission  of  his  symptoms,  and  he 

could  move  bis  hand   and   swallow   as    well   as   ever,  but   gradually   the 

■r  was  again  lost,  and  other  musoles  became  involved.      At  the 

at  time  he  is  almost  entirely  hemiplegia 

Sensibility  is  also  generally  abolished  or  impaired  on  the  paral 
ri  le,  and  thus  the  various  forms  of  numbness,  such  as  tingling,  formi- 
cation, etc.,  are  present. 


134  DISEASES   OF  THE   BRAIN. 

The  mental  symptoms  are  usually  apparent  from  the  first,  but  may 
be  altogether  absent  or  else  so  slightly  shown  as  not  to  attract  atten- 
tion. The  memory  is  impaired,  not  only  as  regards  words,  to  which 
reference  has  already  been  made,  but  also  events  and  circumstances, 
especially  those  of  recent  date.  The  names  of  persons  and  things  are 
likewise  readily  forgotten.  In  the  case  of  a  gentleman  whom  I  saw  in 
consultation,  and  in  whom  I  diagnosticated  thrombosis,  there  was  left 
hemiplegia  involving  both  arm  and  leg,  but  not  the  foot,  which  had 
begun  in  the  fingers  and  gradually  extended.  There  was  no  special 
difficulty  of  speech  except  as  regarded  the  recollection  of  words,  but 
the  memory  was  wonderfully  impaired  in  every  other  respect.  I  en- 
tered his  room  upon  one  occasion  just  as  the  servant  was  carrying  out 
a  tray  with  the  remains  of  his  breakfast.  Not  three  minutes  had 
elapsed  since  he  had  eaten,  and  yet  he  assured  me  he  had  tasted  noth- 
ing since  the  day  before.  The  loss  of  memory  was  the  first  symptom 
observed  in  this  case.  Soon  afterward  he  began  to  improve,  and  he  is 
now,  after  fifteen  months,  free  from  paralysis,  and  with  his  memory 
almost  as  good  as  ever.  The  loss  of  memory  in  such  cases  seems  to  bo 
due  in  the  main  to  the  fact  that  the  power  of  concentrating  the  atten- 
tion upon  any  subject  is  very  much  diminished.  There  is  likewise  an 
indisposition  to  exert  the  powers  of  the  mind  or  body,  and  thus  the 
patient  tends  to  pass  into  a  condition  of  apathy.  Somnolence  is  a  fre- 
quent symptom. 

An  interesting  case  '  of  what  was  probably  cerebral  arterial  throm- 
bosis was  admitted  to  the  New  York  State  Hospital  for  Diseases  of  the 
Nervous  System,  August  22,  1870,  and  came  under  my  observation. 
The  patient,  a  man  forty-one  years  of  age,  was  temperate,  and  had 
never  had  either  syphilis  or  rheumatism.  In  March,  1868,  he  was  seized 
with  a  dull  pain  in  the  right  knee,  accompanied  with  numbness.  There 
soon  followed  formications  and  pricking  sensations,  limited  to  the  right 
foot.  These  gradually  extended  upward,  and,  at  the  end  of  two  weeks, 
had  reached  the  shoulder,  when  he  became  entirely  hemiplegia  Dur- 
ing this  attack  his  consciousness  was  not  affected,  and  his  organs  of 
special  sense,  except  his  touch,  were  unimpaired.  On  the  11th  of 
May  following,  the  patient  suddenly  lost  the  power  of  speech,  but  ex- 
perienced no  disturbance  of  consciousness.  He  remained  completely 
aphasic  for  four  months,  being  only  able  during  this  time  to  utter  a  few 
sounds  which  could  not  be  interpreted  into  intelligible  words.  He  then 
began  to  enunciate  a  few  words,  and  gradually  acquired  more  facib 
ity,  though  his  power  of  coordination  was  far  from  perfect  when  he 
came  to  the  hospital.  His  paralysis  remained  complete  for  nearly  a 
year. 

AVhen  admitted  there  was  hemiplegia  of  the  right  side  of  the  body 

1  See  the  author's  "  Clinical  Lectures  on  Diseases  of  the  Nervous  Sy3tem."    New  York. 
(874,  p.  1.     Case  reported  by  Dr.  T.  M.  B.  Cross. 


PARTIAL   CEREBRAL   ANEMIA,   ETC.  135 

except  the  face;  his  eyesight,  hearing',  and  other  special  senses,  were 
unimpaired,  and  his  intellect  was  clear.  There  was  no  loss  of  the  mem- 
ory of  words,  and  no  impairment  of  the  motor  power  of  the  tongue,  but 
simply  a  defect  in  the  faculty  of  coordination  of  the  muscles  used  in 
articulation.  There  was  more  difficulty  in  pronouncing  labials  and  Un- 
guals than  gutturals.  Tactile  sensibility,  electro-muscular  sensibility, 
and  contractility,  together  with  the  temperature,  were  markedly  dimin- 
ished in  the  right  arm,  while  sensibility  to  pain  and  deep  pressure  was 
normal.     The  bladder  and  rectum  were  not  paralyzed. 

In  talking,  he  had  a  peculiar  hesitating,  stammering  manner,  highly 
characteristic  of  his  disease.  There  were  certain  words  which  he  was 
totally  unable  to  pronounce  with  any  degree  of  accuracy,  even  after 
much  effort — "Peter  Piper" — words  which  begin  with  explosive  labial 
letters,  and  others  similarly  constructed  troubled  him  greatly.  The 
ophthalmoscope  showed  the  existence  of  atrophy  of  both  of  the  disks, 
and  of  retinal  ancemia. 

Under  the  use  of  strychnine  hypodermically  administered,  phospho- 
rus, and  the  primary  current  to  his  brain  and  the  faradaic  to  the  para- 
lyzed parts,  very  marked  improvement  in  all  his  symptoms  was  produced. 
He  regained  a  considerable  amount  of  power  in  the  arm,  became  able 
to  walk  several  miles  at  a  time,  and  acquired  the  ability  to  articulate 
distinctly  any  words  he  wished  to  say.  The  sensibility  returned,  and 
the  nutrition  of  the  affected  limbs  was  manifestly  improved. 

In  another  case,  also  the  subject  of  a  clinical  lecture,1  there  was 
probably  thrombosis  of  the  basilar  artery.  The  patient,  a  woman,  aged 
thirty-five,  while  at  work  wringing  out  clothes  and  exerting  a  good 
deal  of  force,  experienced  a  sensation  of  numbness  in  the  right  arm  and 
leg,  which  was  attended  with  slight  loss  of  power,  though  not  enough  to 
cause  her  to  desist  from  her  labor.  At  the  time  of  the  attack  there 
were  no  head-symptoms  of  any  kind,  and  she  noticed  no  paralysis  of 
the  face.  Her  speech  was  not  affected.  At  the  time  of  her  admission 
into  the  New  York  State  Hospital  for  Diseases  of  the  Nervous  System, 
there  was  paralysis  of  motion  and  sensibility  of  the  right  arm  and  of 
motion  on  the  left  side  of  the  face. 

The  case  was  therefore  one  of  cross-paralysis,  and  it  was  this  fart 
which  mainly  induced  me  to  locate  the  lesion  in  the  pons  Varolii. 

speeoh  was  indistinct,  but  this  was  manifestly  due  to  paraly- 
sis of  the  tongue  and  of  the  other  muscles  ooncerned  in  articulation. 

In  the  oase  in  question  there  had  1 □  aoute  artioular  rheumatism, 

but  the  hear!  was  free  from  functional  or  organio  disease.  The  attack 
was  nol  manifested  with  the  suddenness  which  characterizes  embolism, 
and  there  were  n<>  loss  of  the  faculty  of  Language,  and  no  mental  dis- 
fcurbanee,  which  would  probably  have  resulted  bad  the  middle  cerebral 
artery  been  occluded.      Besides,  the  face   and  the   liml>s  would    bave 

1  Op.  <•;/.,  p,  L80. 


136  DISEASES   OF   THE   BRAIN. 

been  paralyzed  on  the  same  side,  all  of  which  considerations  induced 
me  to  believe  that  the  case  was  one  of  thrombosis  of  a  limited  portion 
of  the  basilar  artery. 

During  the  first  stage  of  thrombosis,  before  the  artery  is  entirely 
closed,  amendment,  and  even  complete  recovery,  may  take  place.  The 
remissions  in  the  symptoms  already  referred  to  are  due  to  the  establish- 
ment of  the  collateral  circulation,  and  this  may  become  so  complete  aa 
to  eventuate  in  cure.  It  must  be  confessed,  however,  that  the  condi- 
tion of  anosmia  to  which  the  foregoing  symptoms  are  due,  in  the  great 
majority  of  cases  ends  in  softening — a  subject  which  will  presently  be 
considered  as  one  of  the  consequences  of  thrombosis  and  other  morbid 
states. 

Causes. — Thrombosis  of  an  artery  may  result  from  atheroma  or 
from  endarteritis,  by  reason  of  which  its  elasticity  is  diminished  and 
the  smoothness  of  its  lining  membrane  destroyed.  Both  these  condi- 
tions retard  the  course  of  the  blood,  and  favor  the  deposition  of  fibrine 
on  the  internal  periphery.  The  walls  of  the  vessels  may  be  healthy, 
and  a  thrombus  may  then  be  formed  through  a  weak  action  of  the 
heart — the  result  of  fatty  degeneration  or  other  cause  impairing  its 
strength. 

Certain  conditions  of  the  system,  such  as  that  which  accompanies 
rheumatism,  may  induce  thrombosis  through  the  excessive  amount  of 
fibrine  present  in  the  blood  and  which  renders  this  fluid  more  readily 
coagulable.  It  is  probable,  also,  that  other  diseases  and  particular 
articles  of  food — as,  for  instance,  alcohol,  fat,  and  starch — when  taken 
in  excess,  especially  when  conjoined  with  insufficient  physical  exercise, 
may  so  alter  the  composition  of  the  blood — inducing  hyperinosis — as  to 
lead  to  a  like  result.  Inordinate  mental  exertion,  tending  as  it  does  to 
diminish  the  tone  of  the  arteries  by  keeping  them  in  a  condition  of  over- 
distention,  may  likewise  cause  the  formation  of  thrombi. 

It  has  apparently  resulted  from  exposure  to  intense  heat,  from  sup- 
pression of  the  menstrual  flow,  from  severe  emotional  disturbance,  and 
from  blows  on  the  head. 

It  is  much  more  common  in  males  than  in  females,  and  in  persons  of 
advanced  years  than  in  the  young. 

Pressure  may  be  exerted  upon  a  cerebral  artery  by  a  tumor  or  other 
extraneous  body,  and  narrowing  of  its  calibre  and  a  consequent  throm- 
bus be  produced.  Gintrac '  cites  a  case  of  the  kind.  A  young  man 
had  suffered  for  several  days  with  headache  and  loss  of  power  in  the 
lower  extremities.  Coma  supervened,  but  he  was  still  able  to  answer 
questions.  There  was  then  pain  in  the  back  of  the  head,  the  pupils 
were  dilated,  the  mouth  was  drawn  to  the  right,  the  respiration  was 
laborious  but  not  stertorous,  and  the  left  side  became  completely 
paralyzed.  He  died  on  the  fifth  day.  On  post-mortem  examination  a 
1  Op,  cit,  tome  i.,  p.  444.     Quoted  from  Roupell,  Medical-  Times,  1844,  vol.  ix.,  p.  370. 


PARTIAL   CEREBRAL  AN.EMIA,   ETC.  137 

firm  clot  was  found  to  occlude  the  right  middle  cerebral  artery,  and  it 
extended  to  the  internal  carotid  artery,  but  did  not  pass  into  the  middle 
cerebral  artery  beyond  th  e  point  of  obstruction.  At  this  place  in  the 
fissure  of  Sylvius  a  small  granulated  mass,  something  like  a  Pacchi- 
onian gland,  pressed  upon  the  artery  and  closed  it.  In  such  a  case  the 
symptoms  will  of  course  be  developed  with  much  greater  rapidity  than 
when  the  cause  of  the  occlusion  resides  in  the  artery  itself. 

Diagnosis. — Arterial  thrombosis  is  distinguished  from  cerebral  con- 
gestion by  the  facts  that  the  mental  and  other  symptoms  are  more  pro- 
found in  character,  and  that  the  patient  has  generally  passed  the  prime 
of  life.  The  existence  of  paralysis  among  the  early  symptoms  will 
likewise  tend  to  the  formation  of  a  correct  opinion.  From  cerebral 
haemorrhage  it  is  diagnosticated  by  the  circumstance  of  its  gradual  de- 
velopment; from  encephalitis  by  the  absence  of  fever  and  the  more 
chronic  nature  of  the  disease;  and  from  embolism  by  its  slow  progress 
and  the  impossibility  of  defining  the  exact  period  of  its  beginning. 

Prognosis. — The  prognosis  in  cerebral  arterial  thrombosis  is  unfa- 
vorable, for  the  reason  that,  although  the  morbid  process  may  advance 
slowly,  and  may  even  be  spontaneously  arrested  in  its  course  before 
the  artery  is  closed,  the  tendency  to  complete  obliteration  is  always 
great,  and  the  chance  of  sufficient  circulation  being  carried  on  by  the 
collateral  vessels  is  very  remote.  The  disposition  to  softening,  there- 
fore, always  exists,  and  generally  cannot  be  overcome.  The  inade- 
quacy of  any  medical  treatment  to  control  the  action  going  on  within 
the  artery,  or  to  aid  to  any  great  extent  in  the  development  of  the 
collateral  circulation,  is  also  an  element  in  forming  an  opinion  as  to  the 
ultimate  result. 

Morbid  Anatomy  and  Pathology. — Although  Virchow '  was  the  first 

to  write  distinctly  in  regard  to  the  nature  of  thrombosis,  the  condition 
was  recognized  long  before  his  researches  were  made,  and  cases  of  clots 
plugging  up  the  vessels  are  to  be  found  detailed  by  many  of  the  older 
medical  authors,  among  whom  Abercrombie,  Cars  well,  and  Cruveilhier, 
may  be  mentioned.  Since  Virchow  began  his  observations  in  this  direc- 
tion, many  instances  have  been  recorded  and  a  large  number  of  memoirs 
have  been  issued  upon  the  subject.  An  interesting  case  was  related  by 
Dr.  Packard,1  of  Philadelphia,  at  a  meeting  of  the  Pathological  Society 
of  that  city  held  in  I  teoember,  1859.  The  patient,  who  had  been  under 
the  care  of  Dr.  Heller,  was  a  bachelor,  fifty-one  years  of  age.  At  six 
ck  in  the  morning,  at  the  beginning  of  February,  he  was  seized  with 
paralysis  <>f  the  left  arm  and  leg.  Be  was  a  man  of  very  regular  habits, 
and  of  fanatical  love  for  every  thing  instructive,  and  an  accomplished 
scholar  in  botany,  geography,  and  languages.  The  paralysis  was  soon 
relieved,  and  he  was  able,  four  weeks  afterward,  to  go  out  again  and  to 

1  Froriep's  en,  1846,  Ben"  xxxvii. 

9  North  Auk,  (Ihirurgical  Review,  vol.  iv.,  1SG0,  p.  306. 


138  DISEASES  OF  THE  BRAIN. 

use  his  arm  tolerably  well.  About  the  middle  of  March,  in  consequence 
of  a  fatiguing  walk  the  previous  evening,  and  an  attack  of  diarrhoea 
during  the  night,  complete  paralysis  returned.  From  this  he  never  re- 
covered, but  yet  did  not  die  till  the  December  following.  Previous  to 
this  termination  he  had  confusion  of  ideas  and  delirium.  Upon  post- 
mortem examination,  among  other  morbid  changes,  a  cavity  in  the  right 
corpus  striatum  was  found,  and  this  was  surrounded  by  a  spot  of  soft- 
ening of  the  cerebral  substance  as  large  as  an  egg.  The  basilar  artery 
was  completely  blocked  up  with  clots,  as  was  also  the  right  carotid. 
These  vessels  were  atheromatous,  and  the  basilar  artery  was  aneuris- 
mally  dilated.     The  clots  had  all  the  appearance  of  being  old. 

Dr.  Dickinson  ■  has  brought  forward  five  cases  of  occlusion  of  arte- 
ries, several  of  which  I  am  disposed  to  think  were  of  embolism,  instead 
of  thrombosis,  as  he  considers  them  to  be.  Dr.  Dickinson  nowhere 
alludes  to  Virchow's  investigations,  but  gives  the  whole  credit  of  the 
discovery  of  the  relation  between  emboli  and  the  formation  of  concre- 
tions in  the  heart  to  Dr.  Kirkes.  The  conclusions  which  he  draws  from 
his  cases  are  by  no  means  original,  although  he  evidently  so  regards 
them. 

The  questions  to  be  considered  in  connection  with  the  morbid 
anatomy  of  arterial  thrombosis  relate  to  the  condition  of  the  artery,  the 
nature  of  the  clot,  and  the  changes  which  take  place  in  those  parts  of 
the  brain  which  are  deprived  of  their  due  supply  of  blood. 

The  affections  of  the  artery,  being  similar  to  those  which  render  it 
liable  to  rupture,  need  not  be  dwelt  upon  at  any  length  here,  as  they 
have  already  been  noticed  under  the  head  of  the  morbid  anatomy  of 
cerebral  haemorrhage.  Suffice  it,  therefore,  to  say  that  endarteritis  and 
atheromatous  degeneration  are  the  diseased  states  generally  met  with. 

The  calibre  of  the  diseased  vessel  is  diminished  and  the  blood  is 
therefore  primarily  obstructed  in  its  course  even  before  the  beginning  of 
the  formation  of  a  clot.  In  addition  the  internal  coat  of  the  artery  is 
roughened,  and  hence  the  fibrine  of  the  blood  is  readily  caught  and  de- 
posited on  the  internal  periphery.  Little  by  little  the  layer  becomes 
thicker  from  fresh  accretions,  until  finally  the  vessel  is  entirely  occluded. 

The  clot  which  closes  the  vessel  is,  in  the  beginning,  coagulated  blood, 
and  hence  consists  of  fibrine  and  white  and  red  blood-corpuscles.  It 
adheres  to  the  arterial  wall  and  may  be  of  a  brown,  yellow,  gray,  or 
white  color.  The  consistence  is  greater  at  the  base  than  at  the  pe- 
riphery, and  it  may  contain  granules  of  calcareous  matter  composed 
mainly  of  phosphate  of  lime.4  The  elements,  with  the  exception  of  the 
fibrine,  are  gradually  disintegrated  and  washed  away  by  the  current  of 

1  "  On  the  Formation  of  Coagulae  in  the  Cerebral  Arteries."  St.  George's  Hospital  Re- 
ports, vol.  i.,  1806,  p.  257. 

2  Lancereaux,  "  De  la  thrombose  et  de  l'embolie  cerebrales.  ThSse  de  Paris,"  1862, 
p.  86. 


PARTIAL   CEREBRAL  ANAEMIA,   ETC,  139 

blood  which  continues  to  flow  through  the  vessel  before  it  is  entirely 
closed,  and  therefore  the  layers  nearest  the  arterial  wall  consist  almost 
entirely  of  fibrine,  and  the  one  nearest  the  centre  of  the  vessel,  which  is 
the  latest  formed,  of  fibrine  and  corpuscles.  An  examination  of  such  a 
clot  with  the  microscope  shows  that  the  above-mentioned  morphological 
elements  are  found  in  its  centre,  more  or  less  changed,  however,  accord- 
ing to  the  age  of  the  formation.  A  thrombus  may  undergo  purulent 
softening  and  disintegration  to  such  an  extent  as  to  result  in  its  break- 
ing up  into  fragments,  which  may  lodge  in  the  vessel  or  its  branches 
farther  on,  and  thus  constitute  emboli. 

The  region  of  the  brain  to  which  the  artery  undergoing  occlusion  is 
distributed  is,  of  course,  deprived  to  some  extent  of  its  blood,  and  hence 
presents  at  first  an  appearance  of  anaemia.  And  this  is  not  prevented 
by  the  increase  of  the  collateral  circulation,  which  is  never  sufficiently 
vigorous  to  compensate  entirely  for  the  loss  by  the  primary  vessel. 

Microscopic  examination  shows  the  capillaries  to  be  smaller  and  less 
numerous  than  in  the  normal  condition,  though  there  is  not  any  palpa- 
ble softening. 

But  after  the  artery  is  entirely  closed  a  change  ensues.  The  anaemic 
portion  of  the  brain  becomes  red  or  pink,  and  this  color  is  deepest  on 
the  borders,  owing  to  the  collateral  circulation  which  is  now  fully  es- 
tablished. This  stage  has  been  called  red  softening,  but  I  am  disposed 
to  think  the  designation  erroneous,  and  that  it  is  liable  to  convey  false 
ideas  of  the  pathology.  For  it  is  perfectly  possible  at  this  time  for  the 
anaemic  portion  of  the  brain  to  be  restored  through  the  activity  of  the 
collateral  circulation,  with  the  effect  of  causing  a  cessation  of  the  symp- 
toms. If,  however,  this  should  be  insufficient  to  provide  for  the  due 
nutrition  of  the  affected  region,  softening  takes  place,  and  a  cure  be- 
comes almost  impossible. 

Obliteration  of  a  cerebral  artery  Dy  thrombus  does  not  always  pro- 
duce notable  symptoms.  For  these  to  follow,  the  morbid  process  must 
b  Bet  up  in  a  vessel  with  but  few  and  small  collateral  branches.  Thus, 
it'  the  internal  carotid  be  obstructed,  the  circulation  is  carried  on  through 
the  circle  of  Willis  by  the  supply  of  blood  derived  from  the  vertebrals. 
The  basilar  artery  mighl  also  be  occluded  at  any  limited  region  between 
a  pair  of  transverse  arteries,  and  the  circulation  still  kept  up  by  the 
carotids  on  the  one  side,  and  the  vertebrals  on  the  other.  But  any 
closure  bo  as  to  involve  one  or  more  of  the  transverse  arteries  must  lead 
to  anaemia,  and  subsequent  softening  of  the  pons  Varolii.  Thus,  in  a 
case  reported  by  Bennett,1  in  whioh  there  had  been  vertigo  and  other 
bead-symptoms  for  several  years,  and  in  whieli  paralysis  of  the  left  arm, 
without  loss  of  consciousness,  had  suddenly  supervened,  the  basilax 
artery  was  found  entirely  obliterated  throughout  its  entire  extent,  all 

1  "Clinical  Leotorea  on  the  Prinoiplea  and  Practice  of  Medicine,"  third  edition,  Euin- 
buryh,  I860,  p.  370. 


140 


DISEASES   OF   THE   BRAIN. 


the  transverse  arteries  were  of  course  closed,  and  the  supply  of  blood  to 
the  pons  was  cut  off  on  both  sides  of  the  mesial  line. 

A  somewhat  similar  case  has  recently  been  reported  to  me  by  a 
physician  of  this  city.  The  patient  had  suffered  with  paresis  of  all  the 
limbs,  with  pain  in  the  back  of  the  head,  occasional  vertigo,  irregu- 
larity of  the  respiration  and  circulation,  and  double  facial  paralysis  for 
several  months.  He  died  suddenly  while  sitting  quietly  in  his  chair. 
On  post-mortem   examination  the  basilar  artery  was  found   occluded, 

Fig.  13. 


a,  artery  of  the  corpus  callosum  (anterior  cerehr.il.  l-icrht'i ;  7>,  middle  cerebral  artery;  c,  posterior  cerebral 
artery;  tf,  superior  cerebellar  artery;  e.  anterior  inferior  cerebellar  arterv ;  /,  posterior  inferior  cere- 
bellar artery;  </.  obliteration  of  artery  of  corpus  callosum  (anterior  cerebral,  right);  h,  obliteration  of 
middle  cerebral  artery ;  i,  obliteration  of  basilar  artery ;  /t,  obliteration  of  vertebral  artery  (left). 

and  distended  by  a  thrombus  which  reached  from  the  point  of  union  of 
the  vertebrals  to  the  posterior  cerebral  arteries,  into  the  left  one  of 
which  it  extended  two  or  three  lines. 

A  very  interesting  memoir  by  Hayem '  alleges  occlusion  of  the 
basilar  artery  by  thrombus  to  be  a  cause  of  sudden  death.  In  all  his 
cases,  four  in  number,  the  artery  was  closed  throughout  a  great  part  of 

1  "  Sur  la  thrombose  par  arterite  du  tronc  basilaire,  comme  cause  du  mort  rapide." 
Archives  <lc  Physiologic  Normale  ct  Pathologique,  1868,  p.  270. 


PARTIAL   CEREBRAL  ANJSMIA,   ETC.  141 

its  extent,  as  the  result  of  extensive  arteritis  and  the  formation  of  dense 
clots.  In  the  fourth  case  there  was  also  thrombosis  of  the  left  middle 
cerebral  artery,  with  difficulty  of  speech. 

The  cerebral  vessels  most  liable  to  be  closed  by  thrombosis  are  the 
internal  carotid,  the  middle  cerebral,  the  basilar  and  the  vertebral ;  after 
these  come  the  anterior  cerebral,  the  posterior  communicating,  and  the 
posterior  cerebral.  It  is  by  no  means  rare  to  find  two  or  more  arteries 
simultaneously  affected,  and  in  one  case  cited  by  Gintrac1  the  whole 
circle  of  Willis  was  obstructed,  and,  in  a  remarkably  interesting  case 
described  by  Heubner,2  the  right  anterior  cerebral  artery,  the  left 
middle  cerebral,  the  basilar,  and  the  left  vertebral  were  obliterated 
by  thrombosis  of  syphilitic  origin  (Fig.  13).  The  arrows  in  the  figure 
represent  the  course  which  the  blood  took  by  reason  of  the  several  ob- 
structions to  its  circulation. 

The  vessels  the  closure  of  which  produces  the  greatest  disturbance 
of  function  are  the  anterior,  middle,  and  posterior  cerebral,  which  supply 
the  hemispheres,  the  corpus  striatum,  optic  thalamus,  and  other  impor- 
tant ganglia.  Besides  the  effect  due  directly  to  the  aneemia,  more  or 
less  disturbance  results  from  the  congestion  posterior  to  the  clot,  and 
the  consequent  effusion  of  serum. 

Treatment. — A  knowledge  of  the  morbid  anatomy  and  pathology  of 
cerebral  arterial  thrombosis  must  satisfy  us  of  the  insufficiency  of  any 
medical  treatment  to  cause  the  absorption  of  the  clot  obliterating  the 
channel  of  the  artery.  Yet  I  have  several  times  heard  it  gravely  pro- 
posed to  administer  the  iodide  of  potassium,  with  the  view  of  accom- 
plishing this  object.  As  regards  facilitating  the  establishment  of  the 
collateral  circulation,  Nature  will  generally  take  care  of  this,  and  may 
even  so  far  overdo  it  as  to  cause  haemorrhage  from  the  rupture  of  ves- 
sels not  accustomed  to  the  increased  tension  of  the  blood.  It  may 
therefore  be  necessary,  in  this  latter  condition  of  excessive  action,  to 
give  the  bromide  of  potassium  in  large  doses.  Should  the  circulation 
be  feeble,  the  skin  cold,  and  the  patient  disposed  to  somnolence,  we 
have  reason  to  suppose  that  the  collateral  circulation  is  not  being  formed 
with  sufficient  rapidity,  and  therefore  the  patient  should  be  kept  with 
the  head  low,  brandy  or  other  spirituous  liquors  administered,  and  the 
body  wrapped  up  in  warm  blankets. 

For  some  time  after  the  successful  establishment  of  the  collateral  cir- 
culation there  is  more  or  less  feebleness  of  mind  and  body.  For  this 
condition  strychnia  and  phosphorus  are  especially  applicable,  and  may 
be  administered  according  to  the  formulas  recommended  under  the 
fiends  of  cerebral  congestion  and  cerebral  hsemorrhage.     Electricity  is 

almost  always  useful. 

1  Op.  <-i/.,  p.  443. 

1  "Die  Luetisohe  Erkraukunj,'  dor  IJirnurterit'ii,"  Leipzig,  1ST  I,  pp,  87,  i'.'4. 


142  DISEASES  OF  THE  BRAIN. 

II. — EMBOLISM    OF   CEREBRAL   ARTERIES. 

Embolism  is  the  term  applied  by  Virchow  to  the  closure  of  an  ar- 
tery by  an  embolus,  which  is  a  clot  formed  in  some  other  part  of  the  body 
and  transported  by  the  current  of  the  blood  to  the  vessel  which  it  oc- 
cludes. It  therefore  differs  from  thrombosis  in  the  facts  that  it  is  not 
associated  with  previous  disease  of  the  artery,  and  that  the  closure  of 
the  vessel  is  sudden. 

Symptoms. — In  cerebral  embolism  there  are  no  premonitory  symp- 
toms. As  in  cerebral  haemorrhage,  the  patient  may  be  sitting  per- 
fectly quiet  when  he  suddenly  loses  consciousness  and  falls  to  the 
ground,  comatose.  As  the  stupor  passes  off,  he  finds  that  he  is  par- 
alyzed upon  the  side  of  the  body  opposite  to  the  seat  of  the  lesion. 

Or  there  may  be  no  coma,  but  merely  slight  confusion  of  ideas  for 
a  moment  or  two  with  sudden  accession  of  paralysis  on  a  limited  por- 
tion of  one  side,  involving  only  the  arm  or  leg.  Or,  again,  the  face  or 
the  tongue  may  be  the  only  part  paralyzed.  Or  there  may  be  no 
paralysis  anywhere,  and  no  mental  symptoms  except  as  regards  the 
faculty  of  language,  which  is  entirely  or  partially  lost. 

Sometimes  there  are  ocular  troubles,  such  as  ptosis,  strabismus,  or 
blindness. 

Experience  shows  that  the  embolus,  for  reasons  which  will  be  given 
hereafter,  generally  lodges  in  the  left  middle  cerebral  artery,  and  that 
with  the  right  hemiplegia — if  there  be  paralysis  at  all — there  is  often 
aberration  of  the  faculty  of  speech. 

The  symptoms  of  mental  derangement,  with  the  exception  of  the  coma 
of  severe  attacks,  are  not  ordinarily  prominent.  I  have,  however, 
witnessed  several  cases  in  which  they  formed  a  very  striking  feature  of 
the  case.  In  one  of  these,  in  which  the  clinical  history  of  the  patient 
disclosed  the  pregxistence  of  several  attacks  of  acute  articular  rheu- 
matism, with  subsequent  endocarditis  and  mitral  and  aortic  valvular 
lesions,  there  were  hallucinations  and  delusions  in  addition  to  the 
complete  paralysis  of  the  left  side.  All  these  phenomena  entirely  dis- 
appeared within  thirty-six  hours.  This  case  is  one  of  the  few  in  my 
experience  in  which  the  embolus  had  occluded  an  artery  on  the  right 
side  of  the  brain. 

In  another,  likewise  with  valvular  disease  of  the  left  side  of  the 
heart,  there  was  delirium  from  the  first,  and  this  disappeared  as  the 
collateral  circulation  was  established. 

Erlenmeyer  has  written  very  excellently  of  cerebral  embolism,  but 
is,  I  think,  incorrect  in  some  points  of  his  symptomatology.  He  states 
the  ordinary  phenomena  of  an  attack  to  be  as  follows: 

There  are  no  prodromata;  sudden  loss  of  consciousness,  with  pa- 
ralysis of  several  parts  of  the  body.  The  facial,  the  hypoglossal,  and 
the  nerves  of  the  extremities,  are  always  more  or  less  affected.     Sensi- 


PARTIAL   CEREBRAL   ANEMIA,   ETC.  143 

bility  is  abolished  in  the  conjunctiva,  but  is  retained  in  the  cornea. 
The  pupils  remain  sensitive,  and  are  neither  contracted  nor  dilated, 
neither  are  there  symptoms  of  concussion  or  compression.  There  are 
no  vomitings  and  no  contractions.  The  pulse  is  weak  and  small,  and 
the  temperature  rather  below  the  normal  standard.  Occasionally  there 
are  epileptiform  convulsions.  Psychical  troubles  do  not  ordinarily  ap- 
pear till  the  collateral  circulation  becomes  active,  and  local  hyperasniia 
is  thus  induced. 

The  principal  exception  I  have  to  make  to  the  foregoing  sequence 
of  symptoms  is  the  too  absolute  assertion  of  the  paralysis  of  the 
facial,  hypoglossal,  and  other  nerves.  I  have  seen  several  cases  in 
which  there  was  no  paralysis  to  be  detected  in  any  part  of  the  body 
by  the  most  careful  examination,  and  several  others  are  on  record. 
In  one  very  interesting  instance,  occurring  in  a  lady  who  had  had 
repeated  attacks  of  acute  rheumatism,  and  who  had  at  the  time 
marked  aortic  insufficiency,  headache  and  vertigo  suddenly  occurred 
while  she  was  conversing  with  a  friend,  and  her  speech  was  cut  short 
with  as  much  suddenness  as  though  she  had  been  shot.  There  was 
no  paralysis  of  the  tongue,  but  all  idea  of  language  was  abolished. 
In  another,  that  of  a  gentleman  with  a  similar  clinical  history,  head- 
ache, vertigo,  confusion  of  ideas,  and  amnesic  aphasia,  suddenly  super- 
vened. That  both  these  were  cases  of  embolism  can  scarcely,  I  think, 
be  doubted. 

And  then,  as  regards  the  state  of  the  pupils,  my  experience  does 
not  coincide  with  that  of  Erlenmeyer,  for  I  have  frequently  found  either 
dilatation  or  contraction  of  both  pupils,  or  dilatation  of  one  and  con- 
traction of  the  other. 

In  examining  a  case  of  recent  embolism,  the  ophthalmoscope  should 
always  be  used  to  view  the  fundus  of  the  eye,  and  even  in  old  cases 
valuable  signs  will  often  be  obtained.  The  middle  cerebral  artery,  the 
ordinary  seat  of  embolus,  arises  from  the  internal  carotid,  after  the  an- 
terior cerebral  and  ophthalmic  have  been  given  off.  Occlusion  of  its 
channel  must,  of  course,  throw  an  increased  amount  of  blood  into  these 
last-named  arteries,  and,  as  the  arteria  centralis  retime  is  derived  from 
the  ophthalmic,  it  and  its  branches  become  enlarged.  The  ophthal- 
moscope will  enable  us  to  discover  the  congestion  thus  produced,  and  will 
often  be  the  means  of  helping  us  to  determine,  La  the  absence  of  pa- 
ralysis, which  side  of  the  brain  is  the  seat  of  the  Lesion.  In  older  cases 
we  will  frequently  find  retinal  congestion. 

The  following  case  I  quote  not  only  as  being  the  first  of  which  I 
have  any  knowledge  in  which  the  ophthalmoscope  was  used  in  a 
of  cerebral  embolism,  but  as  being  interesting  from  the  fact  that  the 
embolus  was'on  the  right  side.     It  is  reported  as 

Cerebral  EJmboliemfolloieing  Valvular  Dieeaet  oftJu  Heart.— John 

Turnbull,  aged  seventeen,  was  admitted  into  the  Hull  General    Infirm- 


144  DISEASES   OF  THE  BRAIK 

ary,  on  April  25,  1867.  He  was  tall,  much  wasted,  and  had  a  suffering 
expression,  and  converging  strabismus  of  the  left  eye,  the  mouth  being 
drawn  very  slightly  toward  the  left  side.  Pulse  70,  very  thrilling  in 
character,  and  a  large  coarse  systolic  murmur  near  the  left  nipple.  He 
was  perfectly  sensible,  complained  of  severe  frontal  headache,  with 
confusion  of  vision,  and  stated  that  he  had  been  in  much  the  same  con- 
dition for  seven  weeks,  his  illness  beginning  spontaneously  with  head- 
ache and  vomiting,  unaccompanied  by  loss  of  consciousness  or  con- 
vulsions. He  had  had  an  attack  of  acute  rheumatism  in  the  previous 
summer.  He  was  ordered  gr.  iij  of  blue-pill  and  gr.  ij  of  extract  of 
henbane  in  a  pill,  and  a  draught  of  acetate  of  ammonia,  three  times  a 
day,  and  spirit-lotion  to  the  head.  "  No  marked  alteration  in  his  con- 
dition, except  progressive  debility,  took  place  till  May  2d,  when  he 
complained  of  increased  headache  and  dimness  of  vision,  and,  being  un- 
able to  expectorate,  from  excessive  weakness,  death  from  bronchial 
obstruction  threatened.  With  the  aid  of  some  champagne,  he  rallied 
in  about  twenty-four  hours,  and  at  the  end  of  a  week  was  much  im 
proved,  having  a  clean  tongue  and  good  appetite,  but  the  headache,  stra 
bismus,  and  deviation  of  the  tongue  to  the  left,  remained.  On  May  16th 
it  was  noticed  that  these  symptoms  had  passed  off,  with  the  exception 
of  the  last  mentioned.     He  was  ordered  a  mineral-acid  mixture. 

"A  week  later,  as  he  still  complained  of  some  dimness  of  sight,  he 
was  examined  with  the  ophthalmoscope.  The  retinal  vessels  were 
found  much  enlarged,  and  the  veins  very  tortuous;  the  optic  nerve- 
entrance  of  an  intense  red  color,  not  being  distinguishable  from  the 
surrounding  parts  except  by  the  entrance  of  the  vessels,  the  redness 
being  chiefly  due  to  a  number  of  very  fine  vessels  radiating  from  the 
centre.  There  was  no  morbid  effusion  in  any  part.  He  could  spell 
easily  from  No.  15  of  Jaeger's  test-types  (being  unable  to  read  and 
write).  He  was  again  examined  at  the  end  of  another  week,  when  the 
optic  nerve-entrance  was  observed  to  be  paler  in  color,  so  that  its  cir- 
cumference could  be  distinguished,  but  still  much  injected,  and  the 
vessels  nearly  as  large  and  tortuous  as  before;  sight  was  apparently 
perfect.     He  was  discharged  convalescent. 

"  The  peculiar  form  of  paralysis  in  this  case  denoted  some  morbid 
condition  within  the  cranium,  which  appeared  to  have  its  most  easy 
and  natural  explanation  in  cerebral  embolism,  an  opinion  further  sup- 
ported by  the  perfect  recovery  of  the  patient.  The  case  received  much 
additional  interest  from  the  information  afforded  by  the  ophthalmo- 
scope, for  one  may  fairly  believe  that  the  intense  congestion  of  the 
retinas  denoted  a  similar  condition  of  the  brain,  perhaps  a  state  of  re- 
action after  the  circulation  had  been  reestablished  through  collateral 
channels." ' 

1  British  Medical  Journal,  1867 ;  also  Quarterly  Journal  of  Psychological  Medicine, 
January,  1868,  p.  178. 


PARTIAL   CEREBRAL   ANAEMIA,   ETC.  145 

CaUSGS. — The  most  common  first  step  in  the  causation  of  cerebral 
embolism  is  acute  articular  rheumatism,  which,  by  inducing  acute  en- 
docarditis, leads  to  the  formation  of  emboli  on  the  valves  of  the  heart 
and  other  parts  of  the  endocardium.  Aneurisms  of  the  aorta  or  othei 
large  artery,  resulting  in  the  coagulation  of  the  blood  in  the  aneurismal 
sacs,  may  likewise  induce  it,  by  a  portion  of  the  clot  being  washed  off 
by  the  current.  Esmarch  '  details  a  case  in  which,  while  an  examina- 
tion was  being  made  of  an  aneurism  of  the  carotid,  the  patient  sud- 
denly fell  back  in  an  apoplectic  stupor.  The  whole  right  side  was  at 
once  paralyzed,  the  facial  muscles  on  the  left  side  were  convulsed,  and 
four  days  afterward  death  ensued.  Post-mortem  examination  showed 
that  the  left  internal  carotid,  the  middle  cerebral,  and  the  ophthalmic, 
were  completely  closed  by  coagula,  which  were  identical  in  structure 
and  appearance  with  the  clot  in  the  aneurismal  sac. 

Emboli  may  also  originate  in  the  lungs,  and,  entering  the  left 
auricle  through  the  pulmonary  veins,  finally  lodge  in  a  cerebral  artery. 

Age  appears  to  exercise  no  influence  over  the  formation  of  emboli, 
but  men  are  much  more  commonly  the  subjects  than  women,  for  the  rea- 
son, undoubtedly,  that  they  are  more  liable  to  attacks  of  rheumatism. 

Of  sixty-two  cases  under  my  care,  either  alone  or  in  consultation, 
in  which  I  had  reason  to  diagnosticate  cerebral  embolism,  there  was 
organic  disease  of  the  heart  in  all  but  four.  Three  of  the  cases  were 
over  sixty  years  of  age;  seven  between  fifty  and  sixty;  eleven  between 
forty  and  fifty;  twenty-nine  between  thirty  and  forty;  and  twelve  under 
thirty.     Thirty-nine  were  males  and  twenty-three  were  females. 

Diagnosis. — From  cerebral  haemorrhage,  embolism  may  be  distin- 
guished by  the  following  signs.  It  occurs  without  relation  to  age, 
while  haemorrhage  is  much  more  frequent  in  persons  over  forty;  there 
are  no  prodromata;  the  resultant  paralysis  is  generally  on  the  right 
side,  while  in  haemorrhage  there  is  no  such  predisposition;  and  it  is  in 
the  great  majority  of  cases  associated  with  organic  disease  of  the  left 
side  of  the  heart.  Care,  however,  must  be  taken  not  to  over-estimate 
the  value  of  this  diagnostic  mark,  valuable  as  it  is.  In  one  case  under 
my  charge,  in  which  the  symptoms  pointed  strongly  to  the  existence 
of  a  cerebral  embolus,  and  in  which,  after  (hath,  the  left  middle  cerebral 
artery  was  found  occluded,  the  heart  was  perfectly  healthy;  and  in  one 
other,  in  which  cerebral  embolus  was  diagnosticated,  and  in  which  there 
was  mitral  regurgitation,  extravasation  into  the  corpus  striatum  was 
discovered  to  be  the  cause  of  death.  A  case  has  recently  been  re- 
ported by  Dr.  J.  Hughlings  Jackson,"  in  which  there  was  Cerebral  DSSm- 
orrhage  with  hemiplegia,  together  with  extensive  valvular  disease  of 
the  heart. 

A  patient  now  in  the  New  York  State    Hospital  for  Diseases  <>f  the 

1  ArehivfUr  Pathologic  Anatomis  und  Phytiologie,  B.  \i.,  1 1 « ■  ft  .">,  1S67. 
» British  Medical  Journal,  October  -J'.',  1870,  i>.  40  I 

11 


146  DISEASES  OF  THE  BRAIN. 

Nervous  System  has  left  hemiplegia,  involving  face,  arm,  and  leg.  It 
has  already  lasted  seven  months,  although  greatly  improved.  The 
hand  and  arm  are  much  contracted.  The  attack  was  apparently  in- 
duced by  strong  muscular  exertion  being  made  while  in  a  stooping  and 
constrained  position.  Most  physicians  will  be  disposed  to  agree  with 
my  diagnosis,  that  the  case  is  one  of  cerebral  haemorrhage,  for  the 
obvious  cause  of  the  paroxysm,  the  lesion  being  on  the  right  side  of  the 
brain,  the  steady  improvement  and  the  muscular  contractions,  all  point 
to  extravasation  of  blood  instead  of  embolus.  Yet  he  is  under  twenty 
years  of  age,  and,  before  the  seizure,  had  an  attack  of  acute  rheumatism, 
with  heart-symptoms.  He  now  has  aortic  and  mitral  regurgitation. 
Such  cases  as  the  above  are  very  instructive,  and  they  show  us  how 
necessary  it  is  to  weigh  all  the  facts,  and  how  great  is  the  possibility 
of  making  a  mistake  after  all.  For,  although  I  am  inclined  to  the  view 
of  haemorrhage,  no  definite  opinion  can  be  given  without  a  post-mor- 
tem examination. 

Still  in  a  case  of  partial  or  complete  hemiplegia,  with  or  without 
apoplexy,  in  which  the  patient  was  below  the  age  of  forty,  with  the 
hemiplegia  involving  the  right  side,  no  muscular  contractions  and  or- 
ganic disease  of  the  left  side  of  the  heart,  with  or  without  previous 
attacks  of  acute  articular  rheumatism,  cerebral  embolus  may  safely  be 
said  to  be  the  cause  of  the  symptoms.  Moreover,  the  paralysis  from 
embolism,  if  it  does  not  disappear  within  seventy-two  hours  after  the 
seizure,  does  not  gradually  fade  away  as  it  so  frequently  does  to  a  great 
extent  in  haemorrhage. 

It  is  a  somewhat  remarkable  fact  that  in  cerebral  embolism  the  pa- 
ralysis may  be  very  extensive  and  complete  without  the  occurrence  of 
other  notable  symptoms.  Thus  in  the  case  of  a  young  lady  whom  I  saw 
in  consultation  with  Drs.  Polk  and  M.  A.  Wilson,  there  had  been  in 
childhood  a  severe  attack  of  inflammatory  rheumatism  and  several  minor 
attacks  subsequently.  On  the  last  day  of  September,  1874,  she  sud- 
denly became  hemiplegic  on  the  left  side,  but  did  not  lose  consciousness. 
There  was  no  aphasia,  pain  in  the  head,  convulsive  movements,  noi 
mental  disturbance.  The  paralysis,  however,  involved  the  left  arm  and 
leg,  and  was  exceedingly  profound.  The  face  was  affected  for  a  short 
time,  but  the  tongue  retained  its  motor  power.  Three  months  after- 
ward she  could  stand  and  walk  a  little,  but  was  not  able  to  raise  the 
foot  from  the  ground;  the  arm  was  absolutely  immovables.  Here  the 
clinical  history,  accompanied  as  it  was  with  a  record  of  heart-disturb- 
ance for  several  years,  was  such  as  to  leave  no  doubt  as  to  the  lesion 
being  embolism  of  an  artery — probably  the  middle  cerebral — of  the 
right  side  of  the  brain. 

The  suddenness  with  which  embolism  takes  place,  to  say  nothing  of 
the  other  points  in  the  clinical  history,  will  suffice  for  the  discrimination 
from  thrombosis. 


PAETIAL   CEREBRAL  ANEMIA,   ETC.  147 

Prognosis. — The  prognosis  in  cerebral  embolism  is  grave,  for  the 
reason  that  the  tendency  to  softening  of  the  anaemic  cerebral  tissue 
always  exists.  But,  if  the  patient  passes  over  the  first  four  or  five  days 
without  any  aggravation  of  his  symptoms,  and  especially  if  they  be 
mitigated  in  violence,  there  is  considerable  hope  of  a  favorable  result. 
Still,  a  guarded  opinion  should  always  be  given  till  all  head-symptoms 
have  disappeared. 

Morbid  Anatomy  and  Pathology. — The  first  rational  explanation  of 
embolism  was  made  by  Virchow,1  in  1847,  who,  in  his  paper  on  acute 
inflammation  of  the  arteries,  distinctly  explained  the  manner  in  which 
the  vessels  were  occluded  by  clots  transported  in  the  blood  from  dis- 
tant parts  of  the  body,  and  who  associated  these  coagula  with  valvular 
disease  of  the  heart.  In  two  of  the  cases  cited  by  him  in  which  arteries 
were  found  closed  by  such  clots,  the  valves  of  the  heart  were  discovered 
to  have  others  still  attached  to  them,  and  exhibited  traces  of  the  sep- 
aration of  those  which  were  found  in  the  vessels. 

Subsequently  (in  1852),  Dr.  Senhouse  Kirkes  a  called  special  atten- 
tion to  the  plugging  up  of  the  middle  cerebral  artery  as  a  cause  of  soft- 
ening of  the  brain.  Three  cases,  in  which  death  followed,  are  adduced, 
in  each  of  which  the  condition  of  non-inflammatory  softening  was  found 
to  exist  in  the  brain.  Dr.  Kirkes's  observations  appear  to  have  been 
made  without  any  knowledge  of  Virchow's  prior  researches.  He  states 
that  the  paralysis  met  with  in  young  persons  may  be  due  to  the  inter- 
ruption of  a  due  supply  of  nutriment  to  the  brain  by  the  occlusion  of 
an  artery  by  a  plug  derived  from  the  left  side  of  the  heart. 

Schlltzenberger,3  among  others,  has  written  with  great  fullness  on 
this  subject.  Among  other  conclusions  not  specially  applicable  to  the 
particular  point  now  under  consideration,  he  states  that  fibrinous  con- 
cretions may  form  in  the  heart  or  large  vessels,  may  subsequently  be 
detached  and  carried  by  the  blood  to  the  cerebral  arteries,  where  they 
produce  symptoms  not  essentially  different  from  those  noticed  in  cere- 
bral haemorrhage  or  acute  softening. 

The  only  material  points  of  difference  under  this  head  between 
thrombosis  and  embolism  are,  the  suddenness  of  the  attack,  the  part  of 
the  brain  most  liable  to  be  affected,  the  origin  of  the  clot,  and  the  state 
of  the  blood-vessel  which  is  obliterated. 

Relative  to  the  first,  the  abrupt  closure  of  a  vessel  as  in  embolism 
will,  of  course,  produce  more  violent  symptoms  than  if  the  occlusion 

1  "  Uebcr  die  akute  Entzundung  der  Arterien."  Arehiv  fttr  Pathol.  Anatomis,  B.  i, 
1847,  p.  272.  Iu  a  paper  on  "Occlusion  of  the  Pulmonary  Artery,"  published  in  Froriep'l 
Neuc Nolizcn  in  1816,  he  enunciated  a  similar  theory. 

1  "  On  some  of  the  Principal  Effects  resulting  from  the  Detachment  of  Fibrinous 
Deposits  from  Che  interior  of  the  Seart,  and  their  Mixture  with  tie  Circulating  Fluid." 
Chirurgieal  Tratuaeiiotu,  vol.  xxxv.,  1852. 

3  Uazdtc  de*  BSpitam,  No.  80,  1857. 


148  DISEASES   OF   THE   BRAIN. 

has  taken  place  gradually,  and  thus  time  have  been  afforded  for  the 
establishment  of  the  collateral  circulation.  In  the  first  case,  not  only 
is  the  blood  at  once  shut  off  from  a  portion  of  the  brain,  but  the  vessels 
behind  the  clot  receive  a  greater  quantity  than  they  normally  do,  and 
hence  the  regions  they  supply  are  immediately  congested.  In  examina- 
tion of  the  brain  of  a  person  who  has  died  during  the  first  stage  of 
cerebral  embolism,  we  find  those  parts  of  the  brain  ordinarily  supplied 
by  the  obliterated  vessel  paler  than  natural,  with  a  zone  of  congested 
tissue,  and  perhaps  numerous  small  extravasations  of  blood  on  the 
periphery. 

The  place  where  emboli  are  most  frequently  found  is,  as  has  already 
been  stated,  the  left  middle  cerebral  artery.  The  left  common  carotid 
arises  from  the  arch  of  the  aorta  in  a  line  almost  exactly  coinciding 
with  the  course  of  the  blood-current.  It  therefore  happens  that  an 
embolus  which  has  formed  on  the  lining  membrane  of  the  heart,  and 
which  has  passed  into  the  aorta  after  having  been  detached,  enters  this 
vessel  instead  of  the  innominata.  From  the  common  carotid  it  passes 
into  the  internal  carotid  and  thence  with  the  stronger  and  more  direct 
current  into  the  middle  cerebral  artery,  which  is  lodged  in  the  fissure 
of  Sylvius.  Of  forty-two  cases  of  cerebral  embolism  collected  by 
Meissner,  in  thirty-four  the  left  hemisphere  was  the  seat.  Of  sixty- 
two  cases  occurring  in  my  own  practice,  and  to  which  reference  has 
been  made,  fifty  were  accompanied  with  right  hemiplegia,  and  were 
consequently  on  the  left  side  of  the  brain.  Post-mortem  examinations 
were  made  in  eleven  of  these  cases,  and  in  all  the  embolus  occupied  the 
left  middle  cerebral  artery. 

Of  these  latter  was  the  case  of  a  prominent  elderly  gentleman  of 
Providence,  Rhode  Island,  whom  I  was  requested  to  visit  in  consul- 
tation with  Drs.  Parsons  and  Collins,  of  that  city..  Three  days  be- 
fore, while  ascending  a  hill,  he  had  suddenly  become  semi-unconscious 
and  hemiplegic  on  the  right  side.  There-  was  also  well-marked  aphasia. 
When  I  saw  him  he  was  in  a  state  of  partial  coma,  from  which  he  could 
be  roused  so  as  to  be  made  to  comprehend,  but  was  unable  to  talk, 
and  was  entirely  paralyzed  in  the  face,  arm,  and  leg,  of  the  right  side. 
The  clinical  history  indicated  the  existence  of  disease  of  the  left  side 
of  the  heart.  I  diagnosticated  an  embolus  of  the  left  middle  cerebral 
artery,  and  expressed  the  opinion  that  death  would  ensue  within  a  few 
hours.  In  both  of  these  views  the  other  medical  gentlemen  fully  con- 
curred. The  patient  died  about  eight  hours  afterward.  The  post- 
mortem examination  was  made  the  following  day,  and  proved  the 
correctness  of  the  opinion  that  had  been  expressed,  for  an  embolus 
completely  occluded  the  left  middle  cerebral  artery,  at  the  point  where 
it  divides  into  the  branches  which  supply  the  island  of  Reil  and  the 
convolutions  of  the  base  of  the  anterior  and  middle  lobes. 

The  pathology  of  the  genesis  of  the  clot  has  already  been  sufficiently 


PARTIAL   CEREBRAL  ANEMIA,   ETC.  149 

dwelt  upon  in  other  connections,  and  the  fact  that  the  artery  in  which 
it  is  found  is  not  diseased  has  been  mentioned. 

The  further  consequences  of  embolism  belong  to  cerebral  softening, 
and  will  be  considered  under  that  head. 

Treatment. — It  is  not  necessary  to  make  any  remarks  on  this  point 
in  addition  to  those  made  in  regard  to  the  treatment  of  thrombosis. 
There  is  very  little  to  be  done  besides  meeting  indications  as  they 
arise,  and  attempting  to  relieve  the  paralysis  and  other  symptoms,  for 
which  ends  my  views  have  been  sufficiently  expressed  in  the  preceding 
chapters. 

III. — THROMBOSIS    OF   CEREBRAL   VEINS    AND    SINUSES. 

It  was,  until  the  researches  of  Virchow,  generally  supposed  that  the 
coagulation  of  the  blood  in  the-  veins  was  the  immediate  result  of 
phlebitis;  but  through  his  investigations  it  is  now  very  well  understood 
that,  in  the  great  majority  of  cases,  the  inflammation  of  the  veins  is  a 
consequence  of  the  formation  of  a  thrombus,  and  not  a  cause.  For 
reasons  which  will  be  given  further  on,  the  sinuses  of  the  dura  mater 
are  especially  liable  to  be  the  seat  of  autocthonous  coagulae. 

Symptoms. — It  is  very  doubtful  if  venous  cerebral  thrombosis  pos- 
sesses such  a  characteristic  symptomatology  as  to  admit  of  its  being 
identified  during  the  life  of  the  patient.  There  are  headache,  convul- 
sions epileptiform  in  character,  paralysis  of  different  parts  of  the  body, 
particularly  of  the  ocular  muscles,  giving  rise  to  squinting  and  double 
vision,  disturbances  of  sensibility,  and,  toward  the  close  of  the  disease, 
coma.     Occasionally  there  is  apoplexy  at  an  early  stage. 

Certain  symptoms  have  been  laid  down  by  authors  as  indicative  of 
the  existence  of  thrombosis  of  particular  sinuses.  Jaccoud,1  however, 
appears  to  discredit  their  importance,  and  I  am  disposed  to  agree  with 
him  that,  though  it  may  be  well  to  know  them,  it  is  safer  not  to  attrib- 
ute to  them  an  absolute  value.  Thus,  Von  Dusch  '  asserts  that  epista  \is 
is  symptomatic  of  obliteration  of  the  superior  longitudinal  sinus  ;  Ger- 
bardt1  finds  a  difference  in  the  size  of  the  external  jugular  veins — that 
of  tin-  affected  side  being  more  collapsed  than  the  other — indioative 
of  thrombosis  of  the  lateral  sinus  ;  Grit-singer*  states  that  the  presence 
of  a  painful  circumscribed  oedema  behind  the  ear  is  evidence  of  the 
existence  of  thrombosis  of  the  transverse  sinus  extending  into  the  veins 
which  lead  to  the  sigmoid  fossa;  and  Corazza  i  thinks  obliteration  of 
tin-  superior  longitudinal  sinus  is  signified  by  (edema  of  the  frontal 

1  "Truitt-  ilc  pathologic  interne,"  tome  premier,  Paris,  1870,  p.  149. 
*  Henleund  Pfeufer'i  "Zeitachrifl  fur  ration.  Medicin,"  B.  vii.,  1859,  p.  161.    Also  die 
N'cu  Sydenham  Translation  -  "  on  Thrombosis  of  the  Cerebral  Sinuses,"  London,  1861. 
1  Deutaehe  Klinik,  1857,  N<>.  46. 

4  "  Beobachtungen  aeber  Birnkrankheiten,"  Arehwdtr  Hnlktmd*,  1858. 
»  "Revista  Clinioa,"  1866. 


150  DISEASES  OF  THE  BRAIN. 

veins,  and  exophthalmos.  An  important  point  in  the  symptomatology 
of  thrombosis  of  the  encephalic  veins  and  sinuses  is  the  often  simulta- 
neous presence  of  suppurative  inflammation  of  the  ear.  This  is  ex- 
plained by  the  fact  that  the  relations  of  the  mastoid  cells  and  the 
petrous  portion  of  the  temporal  bone  to  the  lateral,  the  cavernous,  and 
the  petrosal  sinuses,  are  so  intimate  that  the  extension  of  a  morbid 
process  to  them,  from  the  parts  of  the  cranium  in  question,  is  readily 
accomplished. 

Owing  to  the  inflammatory  action  so  frequently  set  up  in  the  vein 
or  sinus  in  which  a  thrombus  has  been  produced,  pus  enters  the  gen- 
eral circulation,  and  hence  abscesses  are  liable  to  occur  in  distant  parts 
of  the  body. 

In  the  very  interesting  case  which  forms  the  basis  of  Von  Dusch's 
important  paper,  the  principal  phenomenon  observed  during  the  life 
of  the  patient — an  infant  nine  months  old — was  a  large  abscess 
occupying  the  anterior  and  outer  portion  of  the  right  thigh,  from  which 
half  a  pint  of  pus  was  obtained,  by  incision,  and  which  continued  to 
discharge  for  several  days.  Death  occurred  in  a  few  days  without 
being  preceded  by  convulsions,  coma,  or  other  head-symptoms.  On 
examination  after  death,  the  anterior,  part  of  the  superior  longitudinal 
sinus  was  found  to  be  completely  closed  by  a  firm,  pale,  triangular  clot 
of  blood,  adherent  to  the  walls.  Posteriorly  the  clot  did  not  entirely 
fill  the  calibre  of  the  sinus,  and  was  softer.  Similar  clots  were  also 
found  in  the  left  lateral  sinus,  and  in  the  veins  terminating  in  the 
superior  longitudinal  sinus. 

In  a  case  reported  by  Abercrombie '  as  "  Suppuration  within  the 
Left  Lateral  Sinus,"  the  affection  undoubtedly  resulted  from  an  exten- 
sion of  inflammation  from  the  cranium  to  the  veins.  The  patient,  a 
young  lady  aged  sixteen,  complained  of  severe  headache,  which  ex- 
tended over  the  whole  head.  She  had  an  oppressed  look,  and  great 
heaviness  of  the  eyes;  pulse  120;  tongue  clear  and  moist;  face  rather 
pale.  She  had  been  liable  to  suppuration  of  the  ears,  and  the  left  ear 
had  been  discharging  pus  for  three  weeks;  had  complained  of  head- 
ache for  a  fortnight.  A  few  days  afterward,  her  strength  began  to 
fail,  there  was  a  tendency  to  stupor,  and  slight  delirium  was  present. 
There  was  constant  complaint  of  pain  in  the  head.  Finally,  she  became 
more  comatose,  but  was  sensible  when  roused,  and  knew  those  about 
her  a  few  minutes  before  her  death. 

On  post-mortem  examination  the  membranes  of  the  brain  were  found 
congested,  but  the  brain-substance  was  not  diseased.  The  left  lateral 
sinus  was  inflamed  throughout  its  whole  extent.  "  Its  inner  coat  was 
dark-colored,  irregular,  and  fungous.  At  one  place  the  cavity  was 
nearly  obliterated.     The  disease  extended  into  the  torcular  Herophili, 

1  "  Observations  on  Chronic  Inflammation  of  the  Brain  and  its  Membranes."  Edin- 
burgh Medical  and  Surgical  Journal,  vol.  xiv.,  1818,  p.  288. 


PARTIAL    CEREBRAL   ANEMIA,   ETC.  151 

and  affected  a  little  the  termination  of  the  longitudinal  sinus.  Behind 
the  auditory  portion  of  the  temporal  bone,  near  the  foramen  lacerum, 
and  in  the  course  of  the  left  lateral  sinus,  a  portion  of  the  bone  nearly 
the  size  of  a  shilling-  was  dark-colored  and  carious  on  the  inner  table. 
It  was  at  this  place  that  the  sinus  appeared  to  be  most  diseased." 

It  is  stated  that  the  walls  of  the  sinus  were  so  thickened  as  to  pre- 
vent the  passage  of  the  blood,  and  that  evidently  no  blood  had  trav- 
ersed it  for  some  time.  Although  Abercrombie  failed  to  recognize  the 
real  nature  of  the  morbid  process,  there  can  be  no  doubt  that  the  sinus 
was  closed  by  an  old  coagulum,  which  had  been  adherent  to  the  walls, 

Prichard1  reports  the  case  of  a  girl  sixteen  years  of  age,  in  whom 
epileptic  convulsions  had  existed  for  two  years,  and  recurred  very  fre- 
quently, sometimes  several  times  a  day.  There  appeared  to  have  been 
no  other  symptoms  indicating  cerebral  disturbance  except  that  it  is 
mentioned  that  at  one  time  she  was  slightly  delirious,  and  then  was 
free  from  fits.  She  was  treated  actively  for  nine  months,  and  then  died 
in  a  convulsion,  of  the  usual  character. 

Examination  after  death  showed  that  "the  left  lateral  sinus,  through 
its  whole  extent,  was  filled  up  by  a  substance  very  different  in  its 
nature  from  a  recent  coagulum,  and  apparently  consisting  of  a  deposi- 
tion of  lymph,  which  had  become  organized.  It  appeared  so  com- 
pletely to  occupy  the  calibre  of  the  sinus  as  to  have  entirely  impeded 
the  passage  of  the  blood  through  it." 

Another  case,  reported  by  the  same  author,2  is  that  of  a  girl  twenty- 
two  years  of  age,  whose  mother  had  been  insane,  and  whose  complaint 
"began  by  a  feverish  disorder,  under  which  she  labored  about  nine 
weeks.  It  was  followed  by  a  melancholy  and  pensive  habit.  She  was 
observed  to  spend  most  of  her  time  in  reading  religious  books,  and 
attended  a  meeting  of  Calvinistic  dissenters."  When  she  first  came 
under  treatment,  her  appearance  was  very  wild;  she  was  mischievous, 
and  fond  of  destroying  her  clothes.  In  about  three  months  and  a  half 
she  was  discharged  cured,  but  was  readmitted  a  month  afterward,  and 
remained  in  the  hospital  till  her  death,  which  took  place  about  three 
years  subsequently.  During  this  period  her  constitutional  tendency  to 
scrofula  showed  itself  in  a  decided  manner.  The  glands  of  *he  neck 
were  frequently  swollen  and  inflamed,  and  she  was  repeatedly  attacked 
by  pneumonic  symptoms.  When  these  disorders  became  a  little 
relieved,  her  mental  alienation  was  aggravated.  She  generally  sat  with 
her  hands  folded,  and  her  eyes  fixed  downward.  She  died  from  general 
debility  and  exhaustion,  but  without  additional  head-symptoms. 

Post-mortem  examination  revealed  the  existence  of  thickening  of 
the  dura  mater,  serous  effusion  between  this  membrane  and  the  pia 
mater,  fluid,  within  the  pia  mater,  and  thickening  of  this  membrane. 

1  "  A  Treatise  on  Diseases  of  the  Nervous  System."     London,  1822,  p.  176. 
»  Op.  cit.,  p.  357. 


152  DISEASES   OF   THE   BRAIN. 

The  substance  of  the  brain  was  very  firm,  the  pineal  gland  was  large. 
"  The  longitudinal  sinus  contained  a  firm  coagulum,  resembling  a  poly- 
pus, which  extended  into  the  lateral  sinus." 

In  only  one  instance  have  I  had  the  opportunity  of  making  a  post- 
mortem examination  in  a  case  of  thrombosis  of  a  cerebral  sinus.  The 
patient,  a  man  forty  years  of  age,  had  been  upon  a  drunken  debauch 
for  several  days,  when  he  gradually  passed  into  a  condition  of  stupor, 
which  was  at  first  mistaken  for  the  continued  effect  of  alcoholic  intoxi- 
cation. As  it  continued  for  two  days  after  all  stimulants  had  been 
withheld,  this  idea  was  abandoned,  and  the  diagnosis  of  cerebral 
haemorrhage  was  made.  I  saw  him  at  this  time,  and  was  disposed  to 
agree  with  this  opinion.  There  were  profound  stupor,  stertorous 
breathing,  and  complete  resolution  of  all  the  limbs.  Much  to  my 
surprise,  however,  the  state  of  coma  gradually  passed  off,  and  as  sensi- 
bility returned  the  patient  complained  of  intense  pain  in  the  forehead 
and  vertex,  which  was  accompanied  by  twitchings  of  the  muscles  of 
both  sides  of  the  face,  and  of  both  upper  extremities.  On  the  tenth 
day  right  hemiplegia  suddenly  ensued,  unattended  with  loss  of  con- 
sciousness, though  there  was  a  slight  disposition  to  stupor  manifested  as 
soon  as  the  attention  failed  to  be  engaged.  The  pupil  of  the  left  eye  was 
dilated.  On  the  twelfth  day  a  severe  epileptiform  convulsion  ensued, 
which  was  succeeded  by  another  on  the  same  day,  during  which  the 
tongue  was  very  severely  bitten.  Control  of  the  bladder  and  rectum 
was  now  lost,  and  on  the  fourteenth  day  the  convulsive  state  became 
permanently  established,  and  the  patient  died  that  night  without 
regaining  consciousness  though  the  convulsions  became  somewhat  less 
violent. 

The  post-mortem  examination  was  made  the  following  morning. 
The  pi  a  mater  and  arachnoid  were  somewhat  congested,  though  the 
subarachnoideal  fluid  was  not  notably  increased  in  quantity.  The  sub- 
stance of  the  brain  was  healthy,  and  there  was  no  extravasation  of  blood 
anywhere  to  be  found.  But,  on  laying  open  the  longitudinal  sinus, 
a  firm  coagulum  was  found  completely  occluding  it,  from  its  beginning 
anteriorly,  to  its  termination  in  the  torcular  Herophili,  partly  filling 
this  cavity,  being  attached  to  its  anterior  wall,  and  extending  for  the 
distance  of  an  inch  and  a  quarter  into  the  left  lateral  sinus.  The 
thrombus  was  much  more  dense  and  compact  in  its  anterior  than  in  its 
posterior  part,  and  that  portion  which  occupied  the  lateral  sinus  was 
evidently  of  more  recent  formation  than  the  rest. 

A  consideration  of  the  symptoms  exhibited  by  these  cases  will  serve 
to  show  the  truth  of  the  assertion  made  in  the  beginning  of  my 
remarks  on  the  subject,  that  there  are  no  such  characteristic  symptoms 
of  thrombosis  of  the  cerebral  sinuses  as  will  suffice  for  the  identification 
of  the  disease.  The  most  that  can  be  premised  is  a  not  very  decided 
probability. 


PARTIAL   CEREBRAL  ANJEMIA,   ETC.  153 

Causes. — Among  the  causes  of  thrombosis  of  the  cerebral  veins  and 
sinuses,  those  affections  of  the  heart  in  which  the  force  of  its  systole 
is  lessened,  and  those  in  which  there  is  an  obstacle  to  the  return  of 
the  venous  blood,  occupy  a  prominent  place.  Through  the  action  of 
either  of  these  categories  of  diseases  the  circulation  within  the  cranium 
is  retarded,  the  blood  tends  to  accumulate  in  the  large  veins  and 
sinuses,  and,  its  course  being  abnormally  slow,  coagulation  is  liable  to 
ensue.  Tumors  in  the  neck,  by  compressing  the  internal  jugular  veins, 
also  tend  to  the  same  result  by  backing  up  the  blood  in  the  lateral 
sinus.  An  intra-cranial  tumor  may  exercise  a  like  effect  by  direct 
pressure  upon  a  sinus. 

Thrombosis  may  result  from  the  extension  of  inflammation  from  the 
cranium  or  the  cerebral  tissue  to  the  sinuses.  Such  is  the  case  when  the 
suppuration  of  the  ear  terminates  by  the  formation  of  a  thrombus  in 
the  lateral,  cavernous,  or  petrosal  sinus,  or  when  abscess  of  the  brain 
or  an  extravasation  of  blood  produces  a  like  effect.  The  condition  in 
question  may  also  be  caused  by  injuries  of  the  skull;  it  has  been  known 
to  follow  the  operation  of  trephining  and  other  surgical  procedures  on 
the  cranium,  and  may  also  result  from  carbuncles,  of  or  near  the  head, 
and  from  erysipelas  occurring  in  like  situations. 

Age  appears  to  be  of  some  influence  as  a  predisposing  cause  of 
venous  cerebral  thrombosis.  Thus,  of  thirty-seven  cases  cited  by  Gin- 
trac,1  fourteen  were  between  the  ages  of  three  weeks  and  ten  years, 
eleven  between  eleven  and  twenty  years,  six  between  twenty-one  and 
thirty  years,  four  were  forty -five,  fifty-five,  sixty-five,  and  sixty-eight 
years  old  respectively,  and  two  were  of  advanced  age,  not  exactly 
known.  As  Gintrac  remarks,  the  first  period  of  life  is  that  which  is 
most  favorable  to  the  occurrence  of  venous  cerebral  thrombosis,  adoles- 
cence and  adult  age  are  a  little  less  favorable,  and  old  age  is  the  least 
so  of  all. 

Sex  seems  to  be  of  no  predisposing  power:  of  thirty-one  cases  in 
which  the  sex  was  stated,  fifteen  were  males  and  sixteen  females. 

Prognosis. — The  elements  for  forming  a  prognosis  being  of  a  very 
tndeterminate  character,  it  is  difficult  to  form  an  opinion  relative  to 
the  probable  result  in  the  case  of  a  person  presenting  the  symptoms 
which  have  been  mentioned.  It  is  perhaps,  however,  warrant  aide  to 
say  that  thrombosis  of  the  cerebral  veins  or  sinuses  must  from  the  very 
nature  of  the  lesion  bo  a  most  grave  disorder,  if  not  one  necessarily 
fatal,  sooner  or  later.  If  the  vein  or  sinus  in  which  the  clot  exists  be 
small,  and  if  the  causes  be  of  such  a  character  as  to  admit  of  removal, 
and  thus  the  extension  of  the  coagulation  be  preventable,  the  prognosis 
would  of  course  be  more  favorable  than  if  an  opposite  state  of  affairs 
exists.  Alter  all,  the  only  data  from  which  a  judgment  can  be  formed 
ire  the  severity  of  the  symptoms  and  the  course  and  duration  of  the 

>  Op.  et  loc.  «/.,  p.  628. 


154  DISEASES  OF  THE  BRAIN. 

disease.  The  symptoms  themselves  can  be  of  very  little  service  in  this 
respect,  for,  as  we  have  seen,  they  have  no  such  pathognomonic  value  as 
to  indicate  to  us  the  pathological  condition  with  which  we  have  to  deal. 

Diagnosis. — 'After  the  remarks  already  made  incidentally  with  ref- 
erence to  this  point,  there  is  nothing  to  say  which  can  elucidate  the 
sub  j  ect. 

Morbid  Anatomy  and  Pathology. — The  ordinary  seat  of  the  affectioD 
under  consideration,  when  not  the  result  of  some  other  contiguous 
lesion,  is  the  superior  longitudinal  sinus  ;  when  due  to  suppuration  of 
the  ear,  the  clot  is  usually  first  found  in  the  lateral  sinus  ;  when  resulting 
from  injury,  it  has  a  near  topographical  relation  to  the  seat.  Through 
the  occlusion  of  the  sinus  it  becomes  distended  on  the  distal  side  of  the 
clot,  and  the  blood  is  thus  thrown  back  upon  the  capillaries  and  eventu- 
ally upon  the  arteries.  A  state  of  cerebral  ischjemia  is  therefore  in- 
duced, to  which  the  symptoms  of  the  first  stage  of  the  disease  are,  in  the 
main,  to  be  ascribed.  This  ischasmia  may  lead  to  extravasation  of  blood, 
to  inflammation,  or  to  softening.  An  increased  effusion  of  serum  into 
the  sub-arachnoid  space  and  into  the  ventricles  is  an  almost  neces- 
sary consequence.  The  clot  differs  in  character  according  to  its  age. 
When  recent,  it  is  soft  in  consistence  and  almost  black  in  color,  and  is 
not  adherent  to  the  walls  of  the  sinus  in  which  it  is  situated.  When 
old,  it  is  grayish,  dense,  and  unresisting,  and  attached  to  the  wall  of 
the  vessel.  If  it  be  divided,  a  soft,  broken-down  mass  is  often  found 
occupying  the  centre.  This  consists  of  fat  and  other  elements  of  the 
regressive  metamorphosis  which  the  substance  of  the  thrombus  has 
undergone.  It  was  undoubtedly  this  matter  which  Abercrombie  and 
other  writers  mistook  for  pus. 

Other  points  in  the  morbid  anatomy  and  pathology  of  venous  cere- 
bral thrombosis  have  been  sufficiently  considered  in  the  remarks  which 
have  already  been  made. 

Treatment. — There  are  no  means  at  present  known  to  science  by 
which  the  affection  can  be  cured,  or  its  consequences  prevented.  All 
that  can  be  done  is  to  treat  the  symptoms  as  they  arise,  to  search  for 
their  cause,  and  to  remove  the  latter  if  removal  be  possible.  Life  may, 
in  some  cases,  be  prolonged  by  the  judicious  use  of  quinine  and  stimu- 
lants. Convulsions  may  be  lessened  in  force  and  frequency  by  the  em- 
ployment of  the  bromides,  and  pain  assuaged  by  hypodermic  injections 
of  morphia,  by  a  pill  containing  half  a  grain  of  codeia,  given  at  bed- 
time, and  repeated  if  necessary,  or  by  directly  taking  off  a  part  of  the 
intra-cranial  vascular  tension  by  leeches  to  the  inside  of  the  nostrils,  or 
cups  to  the  nape  of  the  neck. 

IV. — EMBOLISM  AND   THROMBOSIS    OF   THE    CEREBRAL   CAPILLARIES. 

The  capillaries  of  the  brain  may  be  occluded  either  by  embolism  or 
thrombosis,  as  are  the  larger  vessels.     But  the  phenomena  of  these 


PARTIAL   CEREBRAL  AXiEMIA,   ETC.  155 

lesions  are  so  indefinite  and  obscure  that  it  is  impossible,  in  the  present 
state  of  our  knowledge,  to  identify  them  during  the  lifetime  of  the  sub- 
ject. There  is,  therefore,  little  to  be  said  relative  to  partial  cerebral 
anaemia  resulting  from  obstruction  of  the  blood  in  the  capillaries,  other 
than  to  call  attention  to  the  genesis,  the  morbid  anatomy,  and  the 
pathology  of  the  processes  in  question.  It  will,  accordingly,  be  more 
convenient  to  consider  the  subject  without  subdivision  into  symptoms, 
causes,  etc. 

Embolism  of  the  cerebral  capillaries  may  be  the  result  of  deposit 
of  pigment^  oifat,  of  pus,  or  of  the  debris  of  various  tissues,  normal  or 
abnormal,  which  have  undergone  decomposition. 

Pigment  may  be  deposited  in  the  capillaries  whenever  the  blood — 
as  it  does  in  certain  diseases — contains  an  abnormal  amount  of  pig- 
mentary corpuscles.  Meckel*  appears  to  have  been  the  first  to  call 
attention  to  the  condition  in  question.  In  the  case  of  a  lunatic,  he  dis- 
covered the  spleen  to  be  enlarged,  and  to  be  covered  with  dark  pig- 
ment. Virchow2  soon  afterward,  in  the  case  of  a  patient  who  had  been 
subject  to  ague,  found  the  spleen  enlarged,  black,  from  excess  of  pig- 
ment, and  the  blood  in  the  heart  to  contain  cells  with  pigment.  Meckel 
attributed  a  great  degree  of  importance  to  the  occurrence  of  melanae- 
mia — as  the  blood-disease  is  called — for  the  reason  that  he  considered 
the  pigmentary  obstruction  of  the  capillaries  a  condition  liable  to  result 
therefrom,  and,  as  a  consequence,  when  those  of  the  brain  are  thus  af- 
fected, the  supervention  of  head-symptoms.  Virchow,  however,  while 
admitting  the  possibility  of  such  a  sequence  of  phenomena,  is  not  able 
to  add  any  facts  tending  to  elucidate  the  subject. 

Frerichs  3  has  called  attention  to  the  pigment  liver  as  associated 
with  pigmentary  emboli  in  the  capillaries  of  the  brain.  Thus  he  says: 
"  The  next  organ  in  point  of  frequency  to  the  liver,  which  undergoes 
important  organic  and  functional  derangements,  is  the  brain.  Numer- 
ous particles  of  pigment,  which  have  passed  unarrested  through  the 
els  of  the  liver  and  the  lungs,  accumulate  in  the  narrow  capillaries 
of  this  organ,  and  particularly  in  those  of  the  cortical  substance.  Even 
by  simple  inspection  of  the  shade  of  color,  we  can  form  an  approximate 
notion  of  the  quantity  of  coloring-matter  which  has  been  deposited,  and 
of  the  extent  of  the  vascular  obstruction.  We  must  not,  however,  rely 
entirely  upon  inspection,  for  slight  accumulations  of  pigment  in  the 
capillaries  easily  escape  notice,  particularly  when  viewed  with  an  un- 
practised eye,  and  can  only  be  distinguished  with  the  assistance  of  the 
microscope.  In  addition  to  the  above,  it  is  not  at  all  uncommon  for  the 
vessels  to  become  obstructed  by  a  colorless  fibrinous-like  ooagulum 
Which  of  course  does  not  affect  the  shade  of  color.     The  meohanioal 

1  Ally.  ZeOschriftfiir  PtyckiatrU,  in  17,  otted  by  Virchow.    "  I>i<-  <'.  Hular-Pathologlc," 
Berlin,  1871,  p.  268,  and  Jaecoud,  op.  cit.,  p.  144.  '•'  Op.  <if. 

1  "Klmik  der  Leberkrankheiten,"  Sydenham  Society  Translation,  vol.  i.,  p.  314. 


156  DISEASES   OF  THE   BRAIX. 

interruption  to  the  circulation  which  is  produced  in  this  way,  not 
unfrequently  gives  rise  to  rupture  of  the  small  vessels,  and  the  forma- 
tion of  numerous  capillary  apoplexies.  Meckel  long  ago  made  observa- 
tions of  this  nature.  Planer  described  eight  cases  in  which  small  ex- 
travasations were  scattered  through  the  gray  and  white  substance  of 
the  brain.  These  numerous  haemorrhages  have  not  come  under  my  own 
observation  ;  but  in  two  cases  I  have  observed  extravasation  into  the 
meninges." 

Frerichs  states  that  he  has  seen  three  cases  in  which  there  were 
functional  derangements  indicative  of  material  changes  in  the  cortical 
substance  of  the  brain.  One  of  them  was  that  of  a  lady  in  her  fortieth 
year,  who,  after  an  attack  of  quotidian  fever,  accompanied  by  somno- 
lence, suffered  from  protracted  loss  of  memory.  The  functions  of  vege- 
tative life  resumed  their  normal  condition,  and  there  were  no  derange- 
ments of  motion  or  sensation  present.  The  headache  and  giddiness 
gradually  diminished  after  the  removal  of  the  intermittent  fever,  by 
means  of  quinine  ;  but  the  weakness  of  memory,  and  the  inability  to 
find  suitable  words  for  objects  and  ideas,  were  still  on  the  increase  two 
months  after  the  cessation  of  the  ague. 

Another  case  was  that  of  a  girl,  aged  nine  years,  living  in  the  same 
district,  where,  according  to  the  evidence  of  two  medical  men,  intermit- 
tent fever,  terminating  fatally,  was  at  the  time  very  prevalent.  This 
girl,  whose  mental  powers  had  previously  been  normal,  had  undergone 
several  attacks  of  tertian  fever.  After  a  protracted  use  of  preparations 
of  bark,  she  recovered  in  her  bodily  symptoms  ;  but  her  mental  facul- 
ties gave  way,  and  a  state  of  complete  idiocy,  accompanied  by  a  raven- 
ous appetite,  supervened. 

In  regard  to  these  cases,  Frerichs  further  remarks  that  it  is  un- 
certain whether  atrophy  of  the  brain  had  resulted  from  occlusion  of  the 
capillaries,  or  whether  it  had  been  induced  by  the  extensive  capillary 
apoplexies  consequent  upon  this  occlusion,  or  whether  the  intermittent 
fever  was  complicated  with  other  accidental  changes  in  the  brain.  He 
gives  the  details  of  several  other  cases  of  intermittent  fever,  accompa- 
nied by  head-symptoms,  and  in  which,  after  death,  the  cerebral  capilla- 
ries— principally  those  of  the  cortical  substance — were  occluded  by  de- 
posits of  pigment,  originating  in  the  liver  and  spleen,  and  transported 
to  the  brain  by  the  current  of  the  circulation. 

A  case  is  reported  by  Bright,1  of  a  man,  who  died  of  paralysis  fol- 
lowing fever,  in  whom  the  cortical  substance  of  the  brain  was  the  color 
of  black-lead. 

Sydenham  had  not  failed  to  notice  the  fact  that  mental  derange- 
ment sometimes  remains  after  intermittent  fever,  which,  if  treated  by 
depletion,  passed  into  imbecility. 

Cases  of  like  character  have  frequently  come  under  my  notice.     7n 
1  "  Reports  of  Medical  Cases,"  London,  1801,  chapter  ci.,  plates  xvii.  and  xix. 


PARTIAL    CEREBRAL  ANAEMIA,   ETC.  157 

one  of  these  there  had  been  repeated  attacks  of  intermittent  fever,  and 
the  spleen  was  greatly  enlarged.  The  patient,  a  young  man  twenty- 
two  years  of  age,  had  suffered  from  epilepsy  for  several  months,  the 
first  paroxysm  ensuing  shortly  after  a  severe  seizure  of  fever,  and  being 
preceded  by  headache,  vertigo,  confusion  of  ideas,  and  twitching  of  the 
muscles  of  the  face.  When  I  first  saw  him  his  mind  was  considerably 
impaired,  and  he  was  having  three  and  sometimes  four  or  five  epileptic 
fits  every  week.  All  his  mental  symptoms  were  improved  by  the  use 
of  arsenic;  his  fits  ceased,  and  his  spleen  became  much  reduced  in  size. 

Those  physicians  who  have  practised  in  malarious  regions  can 
scarcely  have  failed  to  notice  the  fact  that  the  enlarged  livers  and 
spleens,  which  are  so  frequently  produced  by  repeated  febrile  attacks, 
are  often  coexistent  with  cerebral  symptoms,  such  as  have  been  de- 
scribed.1 

The  vessels  of  the  cortical  substance  appear  to  be  more  liable  to  oc- 
clusion from  pigmentary  emboli  than  any  other  part  of  the  brain.  Some 
recent  researches  of  my  own  would  seem  to  show  that  the  vessels  of  the 
retina  are  also  apt  to  be  so  obstructed,  and  that  some  cases  of  pigmen- 
tary deposit  in  the  eye  are  in  reality  instances  of  pigmentary  embolism 
of  the  intra-ocular  vessels. 

Although  the  symptoms  of  the  affection  in  question  have  nothing 
characteristic  about  them,  yet  its  existence  may  be  suspected  with  some 
show  of  probability,  when  pain  in  the  head,  delirium,  convulsions,  ver- 
tigo, paralysis,  and  other  disturbances  of  sensibility  and  motility,  coexist 
with  enlarged  spleen  or  liver,  and  when  there  is  the  previous  history  of 
malarial  fever. 

Embolism  of  the  cerebral  capillaries  from  migration  of  fat  is  a  con- 
dition which  certainly  occurs,  but  which  has  not  as  yet  been  very 
thoroughly  studied.  Todd,1  in  a  woman  who  died  comatose  and  hemi- 
plegia, found  after  death  an  extravasation  of  blood  into  the  right  corpus 
striatum,  and  that  "the  vessels  of  the  softened  portion  of  the  corpus 
striatum,  immediately  surrounding  the  clot,  were  thickly  studded  with 
oil-globules,  which  in  some  situations  were  aggregated  into  dark  masses 
so  large  as  here  and  there  almost  to  fill  up  the  vessels.  The  minutest 
capillaries,  as  well  as  the  larger  arteries,  exhibited  these  deposits,  and  few 
could  be  discovered  without  them. 

Bergmann,'  who  has  devoted  much  attention  to  the  subject  of  fat 

embolism,  has  recently4  reported  a  case  in  which   a  man,  who  died  in 

equenoe  of  injuries  received  from  a  fall,  was  found  to  have  many 

1  A  farther  consideration  will  l>o  given  to  this  very  Interesting  rabjed  in  the  forthoom 
in;,'  memoir  of  the  author,  on  "Pigmentary  Oerobral  Embolism,  and  otln-r  Affections  of 
the  Nervous  System  the  Results  of  Malaria]  Poisoning." 

'  "Clinical  Lectures,"  London,  1861,  p.  733. 

*  "Zur  Lohre  raa  der  Pettembolie."    Dorpat,  1868. 

*  "Ein  Full  tddlioher  Pettembolie."    Berliner  klinUchc  W'ochctwchrift,  No.  83,  1873 


158 


DISEASES   OF   THE   BRAIN. 


hemorrhagic  extravasations  into  the  lungs,  and  numerous  oil-globules 
in  the  pulmonary  capillaries.  The  brain  does  not  appear  to  have  been 
examined,  but  probably  the  cerebral  capillaries  would  have  been  found 
in  a  like  condition. 

In  order  to  throw  additional  light  on  this  subject,  I  have  performed 
a  number  of  experiments  upon  animals,  of  which  the  description  of  one 
will  be  sufficient,  as  the  results  were  analogous  in  all  essential  respects. 

Into  the  left  ventricle  of  the  heart  of  a  medium-sized  dog  sixty  min- 
ims of  olive  oil  were  injected.1  The  animal  was  killed  six  hours  after- 
ward by  section  of  the  medulla  oblongata.  The  brain  was  removed 
from  the  skull  and  carefully  examined.  The  membranes  were  decidedly 
congested.  The  arteries  of  the  base  of  the  brain  contained  numerous  oil- 
globules,  and  this  was  especially  the  case  with  both  the  middle  cerebral 


Fig.  15. 


Fig.  14. 


arteries.  The  minute  terminal  branches  ot  these  vessels  were  filled  with 
fat,  and  several  of  them  were  entirely  occluded.  The  microscope  showed 
the  capillaries  throughout  the  brain,  both  of  the  cortical  and  medullary 
substance,  to  be  gorged  with  fat-globules,  aggregated  in  masses,  so  as 
to  prevent,-  in  many  instances,  the  passage  of  the  blood. 

In  other  experiments  I  allowed  a  longer  time  to  elapse  before  kill- 
ing the  animals,  and  in  one  death  took  place  spontaneously  during  a 
state  of  profound  coma.  The  post-mortem  appearances  were  more 
strongly  marked,  and  in  the  latter  several  centres  of  incipient  softening 
had  been  set  up. 

1  The  heart  was  penetrated  through  the  thoracic  wall  by  the  needle  of  an  hypodermic 
syringe,  and  the  injection  made  very  slowly.  The  left  ventricle  was  chosen  in  order  to 
avoid,  as  far  as  possible,  the  stoppage  of  the  oil  in  the  lungs. 


PARTIAL  CEREBRAL  ANEMIA,  ETC.  159 

Nothing  is  known  relative  to  the  symptomatology  or  pathology  of 
fat-embolism  of  the  cerebral  capillaries,  or  of  the  elements  of  a  correct 
diagnosis  or  prognosis  of  the  affection. 

The  cerebral  capillaries  may  be  obliterated,  as  Virchow '  has  shown, 
by  deposits  of  pus  or  of  the  debris  of  organic  structures  undergoing 
disintegration.  Thus  a  thrombus  undergoes  such  a  transformation  that 
a  puriform  mass  originates  in  its  centre  through  changes  taking  place  in 
the  central  layers  of  the  clot,  and  the  whole  eventually  beeomes  con- 
verted into  a  finely -granular  substance  which  is  capable  of  being  trans- 
ported to  distant  parts  of  the  body  and  occluding  the  smaller  vessels 
and  the  capillaries;  or,  for  instance,  ulceration  following  endocarditis 
takes  place  in  one  of  the  cardiac  valves,  as  a  consequence  of  acute  or 
chronic  softening.  The  minute  fragments  of  the  valve  are  carried  away 
by  the  current  of  the  blood,  and  are  deposited  in  the  vessels  of  remote 
parts,  such  as  the  eyes,  the  brain,  the  kidney,  and  spleen.  The  accom- 
panying cuts  (Figs.  14  and  15)  represent  these  capillary  emboli  in  the 
penicillii  of  the  splenic  artery,  following  endocarditis.  In  Fig.  14  the 
vessels  are  magnified  ten  diameters  ;  in  Fig.  15  three  hundred. 

Whether  such  emboli  are  capable  or  not  of  transferring  specific  dis- 
ease to  other  parts  where  they  are  deposited,  or  whether,  as  some  authors, 
differing  from  Virchow,  assert,  they  merely  act  in  a  mechanical  manner, 
is  as  yet  undetermined.  The  weight  of  evidence  appears  to  favor  the 
view  of  Virchow,  that  they  act  not  only  by  occluding  the  capillaries, 
but  also  by  their  inherent  specificity  originating  new  centres  of  local 
disease. 

Thrombosis. — Thrombosis  of  the  cerebral  capillaries  may,  like  the 
same  condition  of  the  larger  vessels,  result  from  any  cause  capable  of 
inducing  a  stoppage  or  retardation  in  them  of  the  circulation  of  the 
blood.  One  of  the  most  common  of  these  factors  is  calcareous  deposit, 
a  state  which  is  only  to  be  detected  after  death,  and  which,  like  many 
other  analogous  morbid  processes,  was  first  clearly  pointed  out  by  Vir- 
chow.8 According  to  him  it  depends  upon  the  failure  of  the  kidneys  to 
excrete  the  mineral  matter  which  is  taken  up  by  the  blood  from  the 
bones,  and  which  in  consequence  is  deposited  in  other  organs. 

Some  authors  regard  calcareous  deposit  as  being  a  process  more  anal- 
ogous to  embolism  than  to  thrombosis,  but  it  must  be  recollected  that 
the  mineral  substance  is  not  in  a  morphological  state  in  the  blood,  but 
is  held  in  solution  up  to  the  time  of  its  separation  at  the  places  where 
it  is  found,  it  would,  in  my  opinion,  be  equally  logical  to  regard  the 
deposition  of  librine  upon  the  internal  coat  of  a  vessel  as  embolism, 
lor  it  is  held  in  solution  till  it  becomes  attached  to  the  wall,  and  in  this 
respect  does  not  differ  from  the  condition  of  the  calcareous  nuttier. 

1  "Pie  Cellular- Pathologic,"  Berlin,  1871,  p.  237,  d  t,q. 
»  Op.  at.,  p.  252. 


1G0  DISEASES   OF   THE   BRAIN. 

In  the  first  place,  the  serum  of  the  blood  holding  the  mineral  sub- 
stance in  solution  is  probably  infiltrated  through  the  vascular  walls  in  • 
to  the  peri-vascular  tissue  and  the  deposition  effected  there.  Eventual- 
ly, as  the  change  in  the  surrounding  substance  tends  to  prevent  further 
transudation,  and  as  the  vessels  degenerate  from  their  normal  struct- 
ure, the  metastatic  deposit  is  made  around  their  internal  circumference 
and  the  channel  is  finally  occluded.  At  the  same  time  the  capillaries 
lose  their  elasticity  and  become  hard  and  brittle.  The  brain  in  the 
vicinity  of  these  centres  of  morbid  action  may  be  so  saturated  with  the 
calcareous  matter  as  to  give  a  distinct  grating  sound  when  cut,  and  the 
molecules  of  phosphate  or  carbonate  of  lime  may  even  be  seen  with  the 
naked  eye  and  distinctly  felt  when  a  portion  of  the  brain  is  rubbed  be- 
tween the  fingers. 

Marc6  l  reports  the  case  of  a  man,  fifty-five  years  of  age,  who  died  in 
a  state  of  complete  dementia.  On  post-mortem  examination  the  mem- 
branes were  found  adherent  to  the  brain;  in  the  centrum  ovale  of  both 
sides  there  existed  large  lacunae  of  a  yellow  color  and  with  the  appear- 
ance of  elder-pith.  In  addition,  there  were  numerous  calcareous  incrus- 
tations forming  sharp  protuberances  and  giving  a  sensation  to  the  finger 
like  that  experienced  when  the  tongue  of  a  cat  is  gently  rubbed.  The 
capillaries  were  likewise  incrusted.  The  cerebral  substance  contained 
several  old  hemorrhagic  foyers.  The  calcareous  concretions  were  found 
to  consist  of  crystallized  carbonate  of  lime  and  of  the  same  substance  in 
globular  masses.  Subjected  to  the  action  of  dilute  hydrochloric  acid, 
they  were  dissolved  with  the  evolution  of  carbonic-acid  gas;  an  organic 
substance  analogous  in  its  characteristics  to  the  corpora  amylacea  re- 
mained; it  was  not,  however,  colored  blue  by  iodine. 

The  capillaries  surrounding  these  masses  had  undergone  various  de- 
grees of  calcareous  incrustation.  On  some,  the  crystals  were  scattered 
here  and  there  on  the  walls  ;  on  others  they  formed  groups  or  plaques, 
more  or  less  enveloping  the  circumference  of  the  vessel.  There  were 
some  in  which  the  channel  was  entirely  obstructed  by  the  colorless  crys- 
tals, without  any  other  foreign  matter,  fatty,  granular,  or  pigmentary, 
being  present. 

Thrombosis  of  the  cerebral  capillaries  may  also  be  the  consequence 
of  atheromatous  degeneration  and  of  moniliform  dilatation. 

The  white  substance  of  the  cerebrum,  the  cortical  layer,  and  the  cor- 
pora striata  are  more  liable  to  be  the  seats  of  this  process  than  the 
other  parts  of  the  encephalic  mass. 

1  "Bulletin  de  la  soci6t6  anatomique,"  1863,  p.  468,  cited  by  Gintrac,  op.  cit.,  p.  473. 


CEREBRAL   SOFTENING.  1G1 

CHAPTER  VI. 

CEREBRAL     SOFTENING. 

As  a  consequence  of  several  of  the  conditions  described  in  the  fore- 
going pages,  and  especially  as  resulting  from  thrombosis  and  embolism 
in  their  various  forms,  cerebral  softening  naturally  comes  next  in  order 
for  consideration.  Most  authors  treat  of  it  in  direct  connection  with 
obliteration  of  the  cerebral  arteries;  but,  although  frequently  due  to 
this  cause,  it  may  be  produced  by  others,  and  occlusion  is  not  always 
followed  by  softening.  For  these  reasons  I  have  preferred  to  consider 
it  as  it  really  is,  a  distinct  pathological  condition — as  much  so  as  sclero- 
sis or  any  other  morbid  anatomical  state. 

Symptoms. — When  softening  is  the  result  of  hemorrhage,  of  arterial 
embolism,  or  of  arterial  or  venous  thrombosis  or  embolism,  the  symp- 
toms peculiar  to  those  affections  are  first  met  with.  Thus  there  are 
troubles  of  the  intelligence,  the  sensibility,  and  the  power  of  motion, 
such  as  have  already  been  described  under  the  heads  mentioned,  and,  if 
the  morbid  process  goes  on  within  the  cranium  to  its  full  development, 
there  are  peculiar  aggravations  and  the  evolution  of  new  symptoms. 
If  coma  has  existed  from  the  beginning,  it  may  continue  with  little  or 
no  remission,  and  the  patient  may  die  without  regaining  consciousness, 
or  may  become  only  partially  sensible.  The  condition  of  softening  is 
not  usually  set  up  after  either  haemorrhage,  thrombosis,  or  embolism, 
till  about  the  tenth  day,  though  some  cases  are  more  rapid  in  their 
progress,  and  the  symptoms  now  to  be  mentioned  are  those  which  are 
coincident  with  what  some  pathologists  have  designated  the  "  second 
stage;"  the  "yellow  softening"  of  others.  The  "first  stage,"  or  "red 
softening"  of  these  writers,  is,  in  my  opinion,  not  in  reality  softening, 
but  rather  lli"  congestion  due  to  overaction  in  the  collateral  circulation. 

In  addition  to  the  continued  paralysis  of  motion  and  the  loss  of 
ibility  which  exist  on  one  side  of  the  body,  the  mental  symptoms 
become  more  strongly  marked.  There  may  be  delirium  with  the  occur- 
rence of  hallucinations  ami  delusions,  though  these  are  generally  eva- 
nescent. Occasionally  a  fixed  idea  obtains  possession  of  the  pati 
mind,  and  for  a  while  influences  him  in  his  conduct,  but  his  mental 
tenacity  is  not  Btrong  enough  to  enable  him  to  retain  it  for  any  length 
of  time,  so  if  soon  yields  to  another. 

Tie-    intelligence    is  notably  diminished,  so  that   the  patimit   is  unable 

to  conceive  an  exact  idea  of  his  situation,  or  to  obtains  moderately 
complete  n  -:ion  of  quite  simple  matters  which  may  be  submitted  for 
his  mental  action.  Thus  he  refuses  to  credit  the  assertion  that  he  is  ill, 
declares  that  his  health,  both  in  mind  and  body,  is  excellent,  and  that 
U 


162  DISEASES   OF   THE   BRAIN'. 

he  is  fully  capable  of  transacting  his  business  or  of  performing  any 
intellectual  operation. 

The  memory  is  invariably  impaired,  and  things  of  the  greatest 
familiarity  are  forgotten.  Thus  a  patient  laboring  under  cerebral 
softening,  the  result  of  embolism,  could  riot  tell  his  wife's  name,  nor 
by  what  means  he  came  to  my  office.  Another,  sent  to  me  by  Dr. 
Michel,  of  St.  Louis,  in  whom  thrombosis  was  the  probable  cause, 
could  not  tell  me  where  he  came  from,  nor  the  names  of  his  children. 
He  insisted  with  great  vehemence  that  he  was  perfectly  able  to  at- 
tend to  his  ordinary  business,  and  yet  was  unable  to  add  three  numer- 
als together. 

In  another  case,  likewise  having  the  clinical  history  of  thrombo- 
sis, which  I  saw  in  consultation  with  my  friend  Dr.  J.  W.  Ranney, 
of  this  city,  the  patient,  a  gentleman  about  sixty  years  old,  could 
not  tell  his  age  ;  declared  that  Dr.  Ranney,  whom  he  bad  known 
for  many  years,  was  a  grocer,  "who  lived  around  the  corner";  and 
held  to  the  delusion  that  his  sons  had  made  several  forcible  attempts 
to  rob  him. 

The  power  of  giving  the  attention  to  subjects  is  very  greatly  less- 
ened. The  patient  may  seem  to  be  listening  to  what  is  said,  or  observ- 
ing what  is  passing  about  him,  but,  if  he  be  questioned  he  at  once 
shows  that  he  really  has  not  been  heeding  ;  even  when  things  are  for- 
cibly brought  to  his  mind,  and  he  is  told  to  mark  them,  he  is  incapable 
of  doing  so  to  any  considerable  extent. 

The  speech  is  almost  invariably  affected  either  in  the  form  consti- 
tuting aphasia,  or  from  paralysis  of  the  tongue  and  other  muscles  con- 
cerned in  articulation.  There  is  a  disposition  to  misplace  words,  or  to 
clip  them  by  cutting  off  the  last  syllable.  Thus  a  patient  reading  the 
title  of  a  book  in  my  library  called  it  the  "  Unit.  Stat.  Dispenst."  for 
United  States  Dispensatory;  another  was  the  "  Philosoph.  as  Absol. 
Scien."  for  Philosophy  as  Absolute  Science;  and  he  told  me  he  was  "a 
lawy.  by  professi.,"  when  he  meant  to  say  he  was  a  lawyer  by  profes- 
sion. The  same  fault  is  shown  in  reading  from  a  printed  page,  and  in 
writing.  Only  a  few  days  ago  I  received  a  letter  from  a  gentleman,  in 
which  the  final  letter  of  nearly  every  word  was  omitted.  The  emotions, 
especially  those  of  a  sorrowful  character,  are  very  easily  excited,  and 
therefore  the  least  untoward  event  causes  the  exhibition  of  feeling. 
Sometimes  the  patient  sheds  tears  without  being  able  to  assign  any 
cause,  or  may  get  into  uncontrollable  fits  of  weeping;  occasionally  of 
laughing. 

All  these  symptoms  indicate  failure  of  the  mental  power,  but  it  is, 
nevertheless,  true  that  softening  of  the  cerebral  tissue  may  exist  with- 
out the  manifestation  of  the  least  degree  of  imbecility.  It  not  unfre- 
quently  happens  that,  while  there  is  a  general  loss  of  intelligence,  somo 
one  or  two  faculties  of  the  mind  are  notably  increased  in  vigor. 


CEREBRAL  SOFTENING.  163 

I  have  a  patient  now  under  my  charge  whose  intellectual  force  is 
greatly  reduced,  who  cannot  pronounce  the  simplest  sentence  correctly, 
who  is  paralyzed  throughout  the  whoLe  of  one  side,  and  who  has  so 
lost  the  sense  of  propriety  that  if  he  feels  the  desire  to  urinate  he  yields 
to  it  at  once,  no  matter  where  he  may  be  or  who  are  present,  but  whose 
volitional  power  is  even  greater  than  before  the  accession  of  his  disease. 
Thus  he  will  read  volume  after  volume,  turning  over  the  pages  regu- 
larly, and  scarcely,  except  by  oversight,  skipping  a  word,  although  it 
is  very  certain  he  does  not  comprehend  a  tenth  part  of  what  he  reads, 
and  that  what  he  does  for  a  moment  understand  is  immediately  for- 
gotten. The  strength  of  his  will  is  also  shown  in  the  impossibility  of 
inducing  him  to  do  any  thing  which  either  caprice  or  habit  prompts  him 
not  to  do.  His  appreciation  of  harmony  has  become  so  sensitive  that  a 
discord  of  sounds  made  on  the  piano  causes  him  real  mental  suffering, 
whereas  when  he  was  in  health  his  musical  taste  and  discrimination  of 
the  pitch  and  quality  of  sounds  were  below  mediocrity. 

Drowsiness  is  very  generally  present;  at  first,  perhaps,  to  a  slight 
extent,  but  sooner  or  later  as  a  prominent  feature.  Headache  is  very 
common,  and  is  usually  dull  and  circumscribed.  The  forehead  is  its 
most  common  seat.  Other  sensations  in  the  head,  such  as  vertigo;  full- 
ness, weight,  and  constriction,  are  scarcely  ever  absent. 

Gradually,  the  condition  of  the  patient,  mentally  and  physically, 
becomes  weaker  and  weaker,  and  death  ensues,  immediately  preceded 
by  coma,  convulsions,  delirium,  or  a  combination  of  these  phenomena. 

Not  unfrequently,  softening  of  the  brain  is  not  preceded  by  haem- 
orrhage, thrombosis,  embolism,  or  other  evident  affection,  but  begins 
obscurely,  and  advances  very  gradually.  Such  cases  are  often  directly 
due  to  disease  and  obliteration  of  the  cerebral  capillaries,  as  described 
in  the  immediately  preceding  chapter,  or  they  may  be  the  result  of  a 
slow  inflammatory  process.  In  this  form  the  symptoms  make  their  ap- 
pearance in  succession;  but  the  paralysis,  instead  of  being  present  from 
the  Inception,  comes  on  very  slowly,  commencing  as  a  slight  weakness, 

■i 1  with  numbness,  in  one  or  more  of  the  extremities,  or  in  the 

face.  Ordinarily,  the  first  evidence  <>f  paresis  is  discovered  in  the  leg, 
which  is  no i  lifted  clear  of  the  ground.  The  toe  consequently  strikes 
against  the  Inequalities  of  the  pavement,  and  the  patient  is  apt  to  fall. 
Sometimes  the  weakness  is  shown  by  the  leg  suddenly  giving  way  at 
the  knee.  1  have  had  several  patients  with  cerebral  Boftening,  in 
whom  this  accident  was  of  common  occurrence,  and  who  had  thereby 
received  severe  injuries.      (  >r,  when  the  arm  is  t  he   paretio   member,  the 

grasp,  as  shown  by  the  dynamometer,  is  materially  lessened  in  strength, 
and  things  held  in  the  hand  are  dropped.  1  have  now  a  patient  in 
charge  in  whom  the  affection  is  in  its  very  earliest  stages,  and  of  whioh 

the  only  manifestations  are,  dipping  of  the  words  in  Bp» h  and  paresis 

of  one  arm. 


1G4  DISEASES   OF   TFIE   BRAIN. 

This  inability  of  the  muscles  to  maintain  a  continuous  contraction 
for  a  short  time,  though  met  with  in  several  other  affections,  is  to  some 
extent  characteristic  of  cerebral  softening,  and,  in  conjunction  with 
the  other  phenomena,  is  a  valuable  indication.  Even  before  it  has 
become  so  far  developed  as  to  attract  the  attention  of  the  patient  or 
those  about  him,  its  existence  may  be  ascertained  by  means  of  the 
dynamometer  described  in  the  preliminary  chapter  of  this  treatise. 

The  paralysis  usually  goes  on  to  complete  loss  of  power,  though  its 
progress  is  often  very  slow,  and  is  marked  occasionally  by  periods  of 
decided  improvement.  At  these  times  the  patient's  friends  imagine 
that  he  is  about  to  recover,  and  if,  as  is  sometimes  the  case,  the  mental 
symptoms  are  likewise  mitigated,  their  hopes  are  still  further  exalted. 
It  is  necessary  that  the  physician  should  not  be  deceived.  In  a  case 
which  I  saw  in  consultation  with  Dr.  Chamberlain,  of  this  city,  I  diag- 
nosticated chronic  softening.  At  the  time,  there  were  feebleness  of 
memory,  paresis  of  one  side  of  the  body,  and  difficulties  of  speech.  I 
gave  an  unfavorable  prognosis,  but  soon  afterward  amendment  began, 
and  the  patient,  who  was  an  insurance  agent  or  appraiser,  resumed  his 
business  to  some  extent.  I  nevertheless  adhered  to  my  opinion,  for  I 
had  seen  too  many  cases  of  similar  character  to  be  deceived  in  so  clear 
a  one  as  this.  I  never  saw  the  patient  again,  and  am  therefore  unac- 
quainted with  the  subsequent  phenomena,  except  that  about  a  year 
afterward  I  was  invited  by  Dr.  Chamberlain  to  be  present  at  the  post- 
mortem examination.  His  brain  contained  a  foyer  of  softened  tissue  as 
large  as  a  walnut,  apparently  the  result  of  obliteration  of  the  posterior 
branch  of  the  left  middle  cerebral  artery,  and  involving  a  portion  of  the 
middle  lobe  of  the  left  hemisphere. 

In  another  case,  which  I  had  very  thorough  opportunity  for  study- 
ing, the  patient,  a  gentleman  thirty-five  years  of  age,  was  the  subject 
of  chronic  softening,  without  any  history  of  previous  lesions.  The  dis- 
ease had  come  on  very  insidiously,  first  showing  itself  by  a  slight  im- 
pediment of  speech  and  impairment  of  memory.  Gradually  he  lost 
power  in  both  arms  and  both  legs,  though  the  right  side  was  more 
affected  than  the  left.  His  gait  became  titubating,  and  although  he 
never  lost  the  ability  to  walk,  yet  he  did  so  with  great  and  increasing 
difficulty.  But  his  stages  of  apparent  improvement  were  at  first  nu- 
merous and  well  marked.  His  memory  at  such  times  was  stronger,  his 
countenance  brighter,  his  articulation  distinct,  his  emotions  more  under 
command,  his  power  of  attention  increased,  his  intelligence  equal  to  all 
ordinary  occasions,  and  his  walk  free  from  any  sign  of  debility.  Then 
all  these  steps  would  be  suddenly  lost,  and  he  would  again  become 
imbecile  and  weak.  Finally,  a  severe  convulsion,  more  evident  on  the 
right  side  than  the  left,  supervened  one  evening  after  dinner,  as  he  was 
quietly  smoking  a  cigar.  Between  seven  and  twelve  o'clock  that  night 
he  had  over  a  hundred  fits.     He  died  at  the  latter  hour.     The  post- 


CEREBRAL  SOFTENING.  165 

mortem  examination  revealed  the  existence  of  a  large  centre  of  soft- 
ening, involving  the  middle  lobe  of  the  left  hemisphere. 

Sometimes  the  course  of  the  disease  is  still  more  irregular.  No 
evidence  of  cerebral  disorder  is  perceived  beyond  aphasia,  and  the 
patient  remains  in  the  full  possession  of  his  intellect,  and  without  pa- 
ralysis, up  to  a  short  time  before  death.  Durand-Fardel l  cites  the  case 
of  a  man,  thirty  years  of  age,  who  entered  the  Hotel  Dieu,  presenting 
all  the  signs  of  pulmonary  phthisis.  In  a  few  days  afterward  he  expe- 
rienced difficulty  of  articulation,  in  thirty  hours  he  became  comatose, 
and,  in  twenty  more,  died.  The  post-mortem  examination  revealed  the 
existence  of  softening  of  the  inferior  surface  of  the  left  middle  lobe 
of  the  cerebrum.  Although  it  is  not  so  stated — Durand-Fardel  hav- 
ing written  previous  to  Virchow's  observations — there  is  little  doubt 
that  the  cause  of  the  softening  was  an  old  embolus  in  the  left  middle 
cerebral  artery. 

Lallemand,*  in  his  first  letter,  cites  several  cases  in  which  the  dis- 
ease was  marked  by  singular  symptoms,  such  as  convulsions,  contrac- 
tions, and  delirium. 

In  a  case  which  I  saw  in  consultation  with  Prof.  C.  A.  Budd  and 
Dr.  J.  T.  Taylor,  occurring  in  a  gentleman  about  thirty-five  years  of 
age,  there  were  coma  and  violent  hemi-convulsions,  evidently  due  to 
softening  from  embolism,  of  which  there  had  been  two  attacks,  the 
last  several  weeks  previously.  Death  ensued,  but  no  post-mortem  ex- 
amination was,  I  believe,  obtained. 

A  gentleman  is  now  under  my  charge  who  has  valvular  disease  on 
the  left  side  of  the  heart,  the  consequence  of  rheumatic  endocarditis, 
and  who,  six  months  since,  had  an  apoplectic  attack  conjoined  with 
aphasia  and  righl  hemiplegia.  lie  soon  became  able  to  speak  pretty 
well,  and  regained  power  and  sensibility  to  a  great  extent  in  the  para- 
lyzed limbs.  During  the  past  two  weeks,  however,  he  has  exhibited 
symptoms  of  mental  derangement,  as  shown  by  the  existence  of  hal- 
lucinations and  delusions,  and  is  gradually  losing  the  power  of  motion 
and  of  sensation  on  the  right  side.  His  speech  is  as  perfect  as  it  ever 
was,  and  there  is  yet  no  sign  of  dementia. 

It  has  happened  thai  individuals  have  died  who,  on  post-mortem 
examination,  were  found  to  have  softening  of  the  brain,  but  who, 
during  life,  had  exhibited  no  symptoms  of  this  or  any  other  oerebral 
disorder.  Rostan,  who  w;is  the  lirst  to  write  systematically  on  the 
disease,  refers  to  such  oases,  and  Durand  Fardel  is  still  more  explicit. 
The  hitter  says  : 

"We  m. it  with  Boftening  of  the  brain  In  persons  who,  up  to  the 
time  of  death,  had  presented  do  appreciable  derangement  of  the  i 

1  "Tr.iiu'  ilu  ramolltsaement  olrlbrale,"  Parts,  1  s  i :t. 
■  i;     :  i    .•     inatomloo-pathologiquea  sur  L'eno^phale  et  bob  d6pendonces,"  Porta, 


1G6  DISEASES   OF   THE   BRAIN. 

bral  functions,  and  in  whom  softening  has  been  developed  without 
having  given  any  evidence  whatever  of  its  existence."  In  such  in- 
stances the  white  matter  of  the  hemisphere  can  alone  be  involved. 

One  such  case  verified  by  post-morten  examination  has  occurred 
within  my  own  experience.  The  patient,  a  soldier  of  the  Second  United 
States  Infantry,  died  at  Fort  Riley,  in  Kansas,  of  which  post  I  was 
medical  officer,  of  chronic  dysentery,  the  result  of  exposure.  There 
were  no  mental  symptoms,  no  difficulty  of  speech,  no  paralysis;  nothing, 
in  fact,  indicating  the  existence  of  brain-disease.  He  died  in  full  pos- 
session of  his  intellectual  faculties.  The  post-mortem  examination  re- 
vealed the  existence  of  ulceration  of  the  small  intestines,  and,  as  the 
cause  of  death  was  very  evident,  the  brain  was  not  examined.  I  re- 
served it,  however,  for  purposes  of  study,  and,  on  making  a  section  of 
the  right  hemisphere  an  hour  afterward,  discovered  an  encysted  centre 
of  softening,  including  more  than  two-thirds  of  the  posterior  lobe.  The 
right  posterior  cerebral  artery  was  entirely  obliterated  by  thrombosis. 
The  man  had  been  at  the  fort  several  months,  and  had  never  made 
complaint  of  any  illness  till  he  was  attacked  with  dysentery  six  weeks 
before. 

The  duration  of  cerebral  softening  is  very  variable.  Rostan  found 
it  to  range  from  a  few  days  to  several  years.  Andral,  from  an  analysis 
of  one  hundred  and  five  cases,  found  that  the  period  was  from  twelve 
days  to  three  years.  The  most  rapid  case  occurring  in  my  experience 
terminated  in  death  at  the  end  of  eighty  hours.  Some  confusion  on 
this  point  has  arisen  from  the  fact  that  some  authors  regard  embolism 
and  thrombosis  as  essentially  identical  with  softening,  a  doctrine  which 
is  clearly  erroneous,  as,  in  many  cases  of  these  affections,  recovery  or 
death  may  take  place  without  the  stage  of  softening  being  reached. 
In  the  case  above  referred  to,  post-mortem  examination  showed  that 
the  condition  known  as  yellow  softening  was  just'  making  its  appear- 
ance. As  I  have  already  stated,  I  cannot  regard  the  alteration  called 
by  some  pathologists  red  softening  any  thing  more  than  the  congestion 
due  to  the  active  collateral  circulation. 

The  case  of  longest  duration,  of  which  I  have  any  personal  knowl- 
edge, was  that  of  an  eminent  scientific  gentleman,  who  had  suffered 
from  the  symptoms  of  softening  of  the  brain  for  nearly  four  years,  when 
he  died.  There  was  no  post-mortem  examination,  but  the  history  of 
the  case  was  that  of  thrombosis  of  the  left  middle  cerebral  artery,  and 
the  course  of  the  disease  left  no  room  for  doubt  as  to  its  nature. 

The  symptoms  of  cerebral  softening  which  I  have  specified  are 
those  which  are  in  general  the  result  of  the  morbid  processes  existing  in 
the  cortical  substance  of  the  hemispheres,  or  in  the  optic  thalami,  or 
corpora  striata.     Generally,  as  Laborde  '  has  shown,  whenever  the  corti" 

1 "  Le  ramollissemont  et  la  congestion  du  cerveau  principalement  considdres  chez  le 
rieillard,"  Paris,  1866,  p.  1,  el  &eq. 


CEREBRAL   SOFTENING.  167 

cal  substance  is  the  seat  of  softening  there  is  at  least  one  other  centre 
occupying  the  central  part  of  the  brain,  or  especially  the  corpus  stria- 
tum or  optic  thalamus.  But  the  other  portions  of  the  encephalic  mass 
are  liable  to  be  similarly  affected,  and  then  the  phenomena  are  of  a  dif- 
ferent character. 

Thus  the  pons  Varolii  may  undergo  softening  from  occlusion  of  the 
basilar  artery,  or  of  one  or  more  of  its  transverse  branches,  or  from  disease 
of  its  capillaries,  or  from  chronic  inflammation  of  its  substance,  and  if  the 
disease  be  limited  to  this  ganglion  there  is  no  marked  mental  deteriora- 
tion or  other  evidence  of  intellectual  derangement.  The  symptoms  are 
in  the  main  connected  with  sensibility,  and  the  power  of  motion  with  ar- 
ticulation, and  with  the  respiratory,  circulatory,  and  stomachal  functions, 
as  evidenced  by  dyspnoea,  irregular  action  of  the  heart,  and  nausea  and 
vomiting.  In  the  case  of  an  elderly  gentleman  whom  I  saw  in  the  early 
part  of  1874,  and  who  had  been  affected  for  about  a  year,  there  was 
almost  complete  paralysis  of  the  lower  part  of  the  face  on  both  sides, 
there  was  great  difficulty  of  swallowing,  the  tongue  could  not  be  pro- 
truded, speech  was  very  indistinct,  the  respiration  and  action  of  the 
heart  were  irregular,  and  the  limbs  were  partially  paralyzed.  There  was 
a  general  loss  of  sensibility  throughout  the  whole  body,  and  attacks  of 
vertigo  and  epileptiform  convulsions  had  been  frequent.  At  the  same 
time  the  intellect  was  as  clear  and  exact  in  its  operations  as  it  ever  had 
been.  I  diagnosticated  glosso-labio-laryngeal  paralysis,  and  expressed 
the  opinion  that  the  patient  would  not  live  over  a  month.  He  died  in 
two  weeks.  The  post-mortem  examination  showed  the  hemispheres  and 
cerebellum  and  the  membranes  to  be  healthy.  The  basilar  artery  was 
entirely  closed  by  a  thrombus.  The  pons  Varolii  was  as  soft  as  cream, 
and  the  membranes  peeled  off  as  easily  as  if  they  had  never  been  at- 
tached to  it.  Examined  microscopically  after  due  preparation,  the  cap- 
illaries were  found  to  be  in  a  state  of  atheromatous  dog  sneration.  The 
medulla  oblongata  was  not  softened,  but  extreme  atrophy  of  nerve-cells 
had  taken  place  in  the  nuclei  of  the  facial  nerve  of  both  Bides.  This 
point  will  be  further  considered  under  t  he  head  "I'  atrophy  <>f  nerve-cells. 

Softening  of  the  cerebellum  can  scarcely,  in  the  present  state  of  our 
knowledge,  be  diagnosticated  from  any  other  affection  of  that  organ. 

Tiie  rapid  form,  SUCh  ;is  results  from  embolism  of  tin-  larger  viss.'ls,  pre- 
sents so  many  analogies  with  haemorrhage  that  then'  are  no  sure  signs 
by  which  a  discrimination  can  lie  1 1 1  i •  1  ■  • ;  and  the  slow  form  due  to  disease 

of  the  capillaries  or  to  chronic  inflammation  is  not  distinguished  from 
abscess  or  tumor.     Hut,  it  maybe  inferred  that  the  oerebellum  is  the 

seat  of  structural  change  when  (he-  category  of  symptoms  cited  under 
the  head  of  cerebral  hsemon  i  id  the  history  of  the  - 

will  often  aid  us  in  forming  :m  opinion  of  its  nature  not  very  wide  of 

the  mark. 

When  death  results  from  cerebral   softening,  it    may  lie  directly  duo 


1G8  DISEASES   OF   THE   BRAIN. 

either  to  the  disease  itself,  or  to  some  intercurrent  affection.  Thus  the 
patient  may  die  from  pure  exhaustion  or  from  slow  asphyxia  caused  by 
the  imperfect  action  of  the  respiratory  function,  or  he  may  choke  to 
death  either  by  being  unable  to  swallow  food  which  he  has  taken  into 
his  mouth,  or  by  the  regurgitation  of  the  contents  of  the  stomach  during 
a  convulsion,  or  a  severe  convulsive  seizure  may  cause  immediate  as 
phyxia,  or  a  series  of  convulsions  may  produce  a  more  gradual  asphyxia, 
or  he  may  die  in  a  state  of  profound  coma. 

The  intercurrent  affections  may  be  either  meningitis  or  hypostatic 
congestion  of  the  lungs  from  long  confinement  to  the  recumbent  pos- 
ture, or  diarrhoea,  or  a  fresh  attack  of  thrombosis  or  embolism. 

Causes. — The  etiology  of  cerebral  softening  has  already  been  con- 
sidered to  some  extent  under  the  heads  of  cerebral  haemorrhage,  and 
obliteration  of  cerebral  arteries  and  veins  and  of  the  capillaries,  from 
embolism  and  thrombosis,  of  which  conditions  it  is  so  often  a  sequence; 
but,  as  it  may  occur  without  having^  been  preceded  by  either  of  these  or 
other  noticeable  affections,  a  few  additional  observations  are  necessary. 

Age  is  certainly  a  strong  predisposing,  if  not  an  actual  exciting 
cause,  although  the  disease  is  observed  at  all  periods  of  life.  Rostan, 
whose  cases  were  collected  at  the  Salpetriere,  a  hospital  containing  only 
old  women,  found  that  there  were  ten  cases  in  persons  between  the  ages 
of  sixty  and  sixty-nine,  twenty  between  seventy  and  seventy-nine,  and 
ten  between  eighty  and  eighty-seven.  Andral,  excluding  cases  occur- 
ring in  infants,  found  that,  of  one  hundred  and  fifty-three  cases,  there 
were  between  the  ages  of 

15  and  20 10 

20  "     30 18 

30  "     40 11 

40  "     50 19 

50  "     60 27 

60  "     '70 34 

70  "     80 30 

80  "     80 4 

Durand-Fardel,  from  an  analysis  of  fifty-five  cases,  found  between 
the  ages  of 

30  and  40 3 

40     "     50 8 

50     "     55 2 

60     "     10 14 

70     "     80 23 

80     "     87 5 

The  period  of  life,  therefore,  at  which  softening  is  most  apt  to  occur, 
iS  from  the  age  of  fifty  to  eighty. 

During  the  past  ten  years,  forty -five  cases  of  cerebral  softening,  not 


CEREBRAL   SOFTENING.  169 

the  result  either  of  hemorrhage,  arterial  embolism,  or  of  arterial  or  ve- 
nous thrombosis,  have  been  under  my  care  or  been  seen  by  me  in  consulta- 
tion. Of  these,  one  was  under  twenty  years  of  age ;  four  were  between 
twenty  and  thirty  years;  nine  between  thirty  and  forty;  twelve  between 
forty  and  fifty;  eight  between  fifty  and  sixty;  eight  between  sixty  and 
seventy;  and  three  between  seventy  and  eighty.  The  general  results, 
therefore,  go  to  show  the  greater  proclivity  which  advanced  age  gives 
to  the  occurrence  of  the  disease.  In  one  of  those  between  seventy  and 
eighty,  the  mind  was  scarcely  impaired  till  about  two  months  before 
death,  though  there  had  been  paresis,  headache,  and  aphasia,  for  two 
years. 

No  definite  statistics  have  been  collected  relative  to  the  influence  of 
sex,  although  the  opinion  appears  to  prevail  that  the  affection  is  more 
liable  to  occur  in  females  than  in  males.  Of  the  forty-five  cases  just 
cited,  twenty-nine  were  males  and  sixteen  females. 

The  season  of  the  year  does  not  appear  to  exercise  much  influence. 
Durand-Fardel,  from  sixty-three  cases,  found  that  seventeen  occurred  in 
winter,  thirteen  in  spring,  twenty  in  summer,  and  thirteen  in  autumn.  I 
have  found  it  difficult  in  many  cases,  from  the  insidious  or  latent  charac- 
ter of  the  early  symptoms,  to  fix  the  period  of  beginning  with  accuracy. 

Intense  and  long-continued  intellectual  exertion  is  one  of  the  most 
common  causes  of  cerebral  softening.  Eleven  of  the  cases  occurring  in 
my  experience  were  clearly  the  result  of  this  cause.  Severe  and  pro- 
tracted emotional  disturbance  was  apparently  the  cause  in  four  cases. 

llostan,  among  the  causes,  cites  insolation,  the  action  of  intense  cold, 
blows  upon  the  head,  and  excessive  use  of  alcoholic  liquors. 

The  influence  of  obliteration  of  the  cerebral  arteries,  sinuses,  veins, 
and  capillaries,  in  producing  partial  cerebral  anaemia,  and  hence  as  lead- 
ing to  the  supervention  of  softening,  has  already  been  dwelt  upon  at  suf- 
Boient  lengi  h. 

Diagnosis. — The  history  of  haemorrhage,  thrombosis,  or  embolism, 
when  tlnsc  conditions  have  either  of  them  given  rise  to  softening,  will 
aid  in  the  diagnosis,  The  signs  which  serve  to  distinguish  these  affeo- 
tions  from  oth  irs  have  already  been  amply  considered. 

When  there  is  no  such  previous  clinical  history,  softening  of  the 
brain  maybe  confounded  with  chronic  meningitis,  meningeal  haemor- 
rhage, or  tumors.  From  chronic  meningitis  it  is  fco  lie  distinguished  in 
■many  cases  by  the  facts  that  in  the  former  the  headache  is  generally 
diffused,  while  in  Boftening  it  is  fixed,  that  the  paralysis  is  more  limited, 
thai  there  are  Erequenl  spasms  of  the  limbs,  that  there  are  well-marked 
febrile  exacerbations,  and  thai    there  is  not  the  progressive  enfeeble- 

ment  of   the  intellect    so   characteristic  of   the    vast    majority  of   0a8< 

cerebral  softening.     At  the  same  tim..  it  must  be  admitted  thai  the  diag« 

QOsis  sometimes  cannot   be  clearly  made  out. 

In  meningeal  hemorrhage  coma  ooours  as  an  early  symptom,  gradu* 


170  DISEASES   OF  TIIE   BKAIN. 

ally  increasing  in  intensity,  whereas  in  softening  it  comes  on  at  a  late 
period.  Hematoma  of  the  dura  mater,  however,  may  readily  be  con- 
founded with  softening.  The  history  of  the  case  will  aid  in  the  forma- 
tion of  a  correct  diagnosis. 

In  tumors  the  most  prominent  symptoms  are  pain  and  convulsions, 
while  the  intellect  usually  remains  unaffected.  The  pain  is  exceedingly 
intense,  Avhile  in  softening  it  is  dull.  The  speech  in  tumors  is  generally 
unaffected. 

Prognosis. — Cerebral  softening  in  general  ends  in  death.  Neverthe- 
less, it  is  not  altogether  hopeless.  If  the  patient  be  young,  of  good 
constitution,  and  of  temperate  habits  ;  if  the  centre  of  softening  be 
small,  and  not  involving  the  more  important  parts  of  the  brain,  there  is 
some  encouragement  to  expect  a  favorable  termination.  Some  of  the 
cases  cited  in  this  chapter  go  to  show  that  recovery  is  possible,  and  I 
have  certainly  seen  others  with  the  ordinary  initial  symptoms  of  cere- 
bral softening  recover  with  appropriate  medication.  Such  patients, 
however,  were  all  under  the  age  of  forty,  and  were  of  good  constitution 
and  habits.  In  softening  due  to  embolism,  and  occurring  after  rheuma- 
tism and  endocarditis,  the  liability  to  future  attacks  must  not  be  over- 
looked. I  have  seen  as  many  as  six  attacks  of  embolism  occurring  in 
the  same  patient,  and  yet  no  morbid  condition  beyond  that  of  anemia 
set  up,  and  again  cases  in  which  a  single  embolus  has  caused  softening 
and  death. 

Morbid  Anatomy. — In  the  softening  of  the  brain  which  results  from 
the  obliteration  of  arteries  or  veins  by  embolism  or  thrombosis,  the  first 
stage  after  that  of  congestion  from  the  excessive  action  of  the  collateral 
circulation  is  what  is  called  yellow  softening.  This  is  not,  as  some 
authors  have  supposed,  produced  by  the  infiltration  of  pus  into  the 
cerebral  substance,  but  is  caused  by  regressive  metamorphosis  of  the 
brain-cells  into  fat,  the  granules  of  which  are  mixed  with  the  coloring 
matter  of  the  blood  which  gives  rise  to  the  peculiar  yellow  color.  The 
white  corpuscles  of  the  blood  also  undergo  degeneration  into  fat. 

These  altered  white  corpuscles  were  described  by  Gluge  '  as  inflam- 
mation corpuscles,  under  the  idea  that  softening  was  always  the  result 
of  inflammation.  Laborde,*  who  has  studied  this  subject  with  great 
success,  shows,  however,  very  conclusively  that  the  transformation  is  a 
true  degeneration,  a  part  of  the  fat-corpuscles  being  derived,  as  stated 
above,  from  the  nervous  fibres,  the  cylinders  of  which  disappear,  tho. 
contents  being  extravasated,  and  with  the  myeline  being  converted  into 
fat;  and  another  part  consisting  of  altered  white  blood-corpuscles.  At 
this  time  the  cerebral  tissue  is  pulpy,  constituting  a  centre  of  softening 
or  a,  foyer,  the  consistence  of  which  is  greater  at  the  circumference  than 
at  the  centre.     The  blood-vessels  passing  through  the  disorganized  por- 

1  "  Atlas  of  Pathological  Histology."     Translated  by  Leidy.     Philadelphia,  1853. 
1  Op.  cit. 


CEREBRAL   SOFTENING.  171 

tion  are  easily  separated  from  the  perivascular  tissue  and  are  covered 
with  oil-globules. 

The  second  stage  is  designated  white  softening,  and  in  it  the  brain- 
substance  loses  altogether  its  morphological  characteristics,  and  appears 
as  a  white,  cream-like  matter  so  soft  that  a  weak  stream  of  water,  al- 
lowed to  impinge  upon  it,  washes  it  away.  In  this  semi-liquid  matter, 
whitish  flakes  of  denser  tissue  are  suspended.  Microscopical  examina- 
tion shows  that  all  traces  of  nervous  structure  have  disappeared,  and 
that  no  anatomical  elements  remain  except  oil-globules  and  organic  cor- 
puscles somewhat  resembling  leucocytes. 

When  the  morbid  process  involves  the  cortical  substance  of  the 
cerebrum,  the  convolutions  undergo  a  peculiar  kind  of  transformation 
first  pointed  out  by  Cruveilhier,  and  then  by  Durand-Fardel 1  as  occur- 
ring in  the  senile  form  of  softening. 

This  is  characterized  by  the  formation  of  yellow  plates,  irregular  in 
form,  soft  to  the  touch,  but  yet  sufficiently  dense  to  resist  the  action  of 
a  thin  stream  of  water.  Microscopically  they  are  seen  to  consist  of 
nucleated  fibres,  fat-corpuscles,  fat -globules,  and  degenerated  capillaries, 
with  blood-crystals  and  granular  matter.  Essentially,  therefore,  they  are 
formed  of  connective  tissue. 

The  degenerated  nerve-tissues,  constituting  a  focus  of  softening, 
may  undergo  absorption.  In  such  a  case,  a  cicatrix,  similar  in  general 
characteristics  to  that  resulting  from  the  curative  process  of  haemorrhage, 
remains. 

In  the  softening  resulting  from  inflammation,  a  somewhat  different 
set  of  morbid  appearances  exists.  Thrombosis  and  embolism  produce  a 
true  death  of  the  parts  previously  supplied  by  the  occluded  vessels,  a  ne- 
crobiosis, as  it  has  been  called  by  Virchow.  The  process  is  accompanied, 
as  we  have  seen,  by  degeneration  of  the  nervous  tissue,  but  in  the  soft- 
ening due  to  inflammation  new  formations  result.  Sometimes  the  two 
coexist,  but  the  latter  is  occasionally  an  entirely  independent  action. 

When  such  is  the  case,  connective  tissue  is  generated,  and  the  aer- 
vous  substance  is  rapidly  broken  down.  An  exudation  <>f  an  albumi- 
nous fluid  containing  line  granules,  the  disintegral Lng  nervous  Bubstanoe 
and  numerous  Hakes  of  coagulated  fibrine,  takes  place,  and  with  blood- 
corpuscles  causes  the  centre  of  softening  to  present  the  appearance  of  a 
reddish  pultaceous  mass,  easily  washed  away  by  the  action  of  a  weak 
stream  of  water.  With  age  the  oolorof  this  softened  tissue  becomes 
brown  or  yellow.  Sometimes,  when  the  inflammation  has  extended  to 
the  deeper  parts  of  the  oerebrum,  the  contents  of  the  oysi  are  pene- 
trated by  the  new  connective  tissue.    The  pulpy  mass  undi  irtial 

absorption,  and  is    replaced    by  a  while    turbid    liquid,  called    by  <  Yusei]- 

bier  and  Dechambre  "milk  of  lime"   (lail  de  ohaux).      Durand-Fard  1 
nates  this  form  of  softening  "cellular  infiltration." 

1  "  Maladies  des  vicillards,"  Paris,  ltf.M,  j>.  7_. 


172  DISEASES   OF   THE   BRAIN. 

The  softening  resulting  from  occlusion  of  the  capillaries,  a  condition 
not  recognizable  during  life,  does  not  differ  essentially,  except  in  its 
situation,  from  that  which  follows  embolism  or  thrombosis  of  the  larger 
vessels.  The  centres  of  the  process  are,  however,  smaller,  are  generally 
numerous,  and  usually  met  with  either  in  the  cortical  or  white  sub- 
stance, or  in  the  corpora  striata.  The  morbid  anatomy  of  the  affected 
vessels  has  been  sufficiently  considered  in  the  previous  chapter. 

When  disease  of  the  capillaries  has  been  the  cause  of  the  softening, 
these  may  be  ruptured,  and  we  meet  with  minute  extravasations  of 
blood  in  the  disintegrated  perivascular  tissue,  constituting  the  "  capillary 
haemorrhage  "  of  Cruveilhier. 

Pathology. — The  first  definite  accounts  of  cerebral  softening  were 
given  by  Lallemand '  and  Rostan,2  both  of  whom  published  their  works 
in  the  same  year,  1820. 

In  the  very  beginning  of  his  first  letter,  Lallemand  awards  to  MM. 
Recamier,  Bayle,  and  Cayot,  the  credit  of  describing  the  condition  under 
consideration,  and  of  giving  it  the  designation  by  which  it  is  so  general- 
ly known,  even  out  of  France,  of  ramollissement.  Lallemand  then  pro- 
ceeds to  define  the  term  by  saying  that,  by  ramollissement  of  the  brain, 
he  understands  a  kind  of  liquefaction  of  a  part  of  its  substance,  the  re- 
mainder preserving  its  ordinary  consistence.  He  then  quotes  eases 
from  Morgagni  and  Abercrombie,  and  cites  others  from  his  own  experi- 
ence; and  then  concludes  by  declaring  that  he  does  not  hesitate  to 
range  cerebral  softening  among  the  inflammations,  in  which  opinion  he 
is  supported  by  Abercrombie.3  Rostan  4  regarded  the  disease  as  some- 
times being  due  to  inflammation,  and  sometimes  to  degeneration  of  the 
blood-vessels.  Bouillaud  5  viewed  it  as  an  anatomical  feature  of  inflam- 
mation. Cruveilhier "  considered  what  he  called  red  softening  as  result- 
ing from  the  capillary  haemorrhage  previously  mentioned,  and  that  other 
forms  were  certainly  due  to  inflammation. 

Andral 7  recognized  the  fact  that  softening  might  result  from  inflam- 
mation or  capillary  haemorrhage,  but  he  also  insisted  that  it  might  be 
due  to  special  alterations  of  nutrition,  caused  by  different  morbid  influ- 
ences, such  as  obliteration  of  the  arteries  supplying  the  brain,  or  im- 
poverishment of  the  blood. 

.MAI.  de  la  Berge  and  Monneret8  adopted  in  part  the  views  of  Ros- 
tan relative  to  degeneration  of  the  cerebral  vessels  as  a  cause  of  soften- 

1  "  Recherches  anatomico-pathologiques  sur  l'encephale,"  Paris,  1820. 
2"Recherches    sur  le  ramollissement  du  cerveau,"  Paris,  1820.      My  references  to 
Rostan's  work  are  to  the  second  edition,  of  1823. 

3  Op.  at.,  p.  205.  4  Op.  cit.,  chapter  vii. 

6  "Trait6  de  l'encephalite,"  Paris,  1825. 

•  Art.  "  Apoplcxie,"  in  "  Dictionnaire  de  m6decine  et  de  chirurgie  pratique*." 
T  "Cliniquc  medicale." 

*  "Compendium  de  m^decine  pratique." 


CEREBRAL   SOFTENING.  173 

ing.  Carswell '  regarded  softening  occurring  during  life  as  being  af- 
fected by  these  circumstances — inflammation,  obliteration  of  arteries, 
and  modification  of  nutrition. 

Fuchs 2  appears  to  think  that  inflammation  is  not  a  necessary  ante- 
cedent, but  that  congestion  is.  He  also  admits  obstruction  of  the 
arteries  at  the  base  of  the  brain  to  be  a  cause. 

The  studies  of  Durand-Fardel 3  have  been  very  thorough,  and  have 
contributed  greatly  to  our  knowledge  of  cerebral  softening.  According 
to  him,  the  affection  is  an  inflammation  which  does  not  differ  essentially 
from  other  inflammations  occurring  in  the  young  or  old.  White  soften- 
ing he  regards  as  the  chronic  form  of  the  disease. 

Other  pathologists  published  the  results  of  their  observations  and 
generally  to  the  same  effect  as  those  which  have  been  quoted,  viz.,  that 
cerebral  softening  was  an  inflammatory  process,  and  sometimes  one  re- 
sulting from  obliteration  or  disease  of  the  arteries.  A  few,  however, 
held  to  the  view  of  Lallemand  and  Durand-Fardel,  that  inflammation 
was  always  the  starting-point. 

In  18-ii  Virchow  published  his  observations  relative  to  embolism,  and 
the  partial  cerebral  anaemia  produced  by  occlusion  of  an  artery  thus  be- 
came a  recognized  fact.  In  reality,  it  came  to  be  regarded  as  the  only 
cause  capable  of  giving  rise  to  softening,  and  many  pathologists  of  the 
present  day  entertain  such  an  opinion.  But  I  think  this  is  carrying  the 
theory  further  than  facts  will  warrant.  I  cannot  altogether  disregard 
the  researches  of  Durand-Fardel,4  Calmeil,6  Rokitansky,*  Wedl,7  and 
others,  and  although  I  cannot  agree  that  all  cerebral  softening  is  a  con- 
sequence of  inflammation,  I  am  very  sure  it  has  this  and  other  causes 
besides  thrombosis  and  embolism.  Calmeil's  work  is  a  monument  of 
careful  observations  and  scientific  deductions,  and  his  fifth  chapter  (tome 
ii.),  entitled  "  iJu  rmaollissement  ctrebral  local*aiyu,  on  de  Vencdpha- 
lite  locale  aiffuS  sans  caillots  sanguins  sihgeant  sous  la-forme  (Fun  foyer 
ou  des  plus! curs  foyers  circonscrits,  soit  a  la  surface^  soii  dans  la  pro- 
fondeur  tie  la  masse  encbphalique"  contains  cases  which  are  amply 
sufficient  to  establish  the  point  for  which  he  contends.  He  shows,  too, 
in  other  chapters  of  his  treatise,  that  softening  results  about  tin-  periph- 
ery of  clots  due  to  cerebral  haemorrhage. 

The  weak  feature  of  Calmeil's  otherwise  very  oomplete  work  is,  that 
he  altogether  ignores  Virchow,  and  those  after  him,  \\  ho  have  confirmed 
his  facts  and  theories. 

1  Art  "Softening of  Organs,"  in  "Cyclopedia  of  Practical  Medicine,"  rot  It.,  p.  17ft, 
American  edition, 

•  •*  Bedbachtungen  and  Bemerkangeo  Qber  Gehlrnerweichung,"  Leipzig  1838. 

8  "  Tr.iin''  « 1 1 1  ramollissement  dn  ceireau,"  Paris,  1848. 

4  "  Maladies  des  vieillards,"  Paris,  I  86 1. 

6  "  Tralte-  des  maladies  Inflamraatoires  'In  oerreau,"  Paris,  I  - 

1  "  Pathological  anatomy,"  Sydenham  Society  translation,  I860. 

1  "Budimenta  of  Pathological  Histology,"  Sydenham  Bodetj  translation,  1855. 


1?4  DISEASES   OF  THE   BRAIN. 

Soulier,1  on  the  other  hand,  can  see  in  softening  nothing  of  the 
nature  of  inflammation.  For  him  it  is  always  a  necrobiosis,  produced 
by  the  cessation  of  the  physiological  action  of  the  blood,  obliteration  by 
embolus  or  thrombus,  by  diminution  of  the  calibre  of  the  vessels,  or  oc- 
clusion resulting  from  atheroma  or  obstruction  of  a  vein  or  sinus.  He 
admits  that  the  obliteration  of  an  artery  may  cause  congestion  behind 
the  point  of  obstruction,  by  which  the  coagulation  and  capillary  haemor- 
rhage of  acute  softening — the  capillary  apoplexy  of  Cruveilhier — are  to 
be  explained.  This  red  ramollissement  has,  however,  nothing  of  the 
nature  of  inflammation  about  it. 

The  only  points  in  which  I  differ  with  Soulier  are,  that  I  cannot 
regard  softening  as  being  solely  due  to  occlusion  of  blood-vessels,  and 
that  I  am  very  sure  the  congestion  which  follows  thrombosis  or  embo- 
lism is  not  necessarily  the  first  stage  of  softening.  There  is  no  more 
reason  why  partial  cerebral  anaemia  should  always  result  in  softening, 
than  that  ligation  of  the  femoral  artery  should  always  lead  to  gangrene 
of  the  parts  below. 

Obstruction  of  veins  and  sinuses  in  the  brain  may  be  followed  by 
softening.  The  clot  is  usually  the  result  of  injuries  or  disease  of  the 
cranial  bones  or  cerebral  membranes,  especially  the  dura  mater.  It  may 
also  be  caused  by  certain  cachectic  conditions  in  which  the  blood  is 
deteriorated  in  quality,  such  as  typhus  and  typhoid  fevers  and 
cholera. 

Four  cases,  in  which  this  latter  affection  was  followed  by  thrombo- 
sis of  the  superior  longitudinal  sinuses,  with  consecutive  softening,  have 
come  under  my  observation.  In  two  of  them  there  were  also  thrombi 
in  both  femoral  veins.  The  upper  surfaces  of  both  hemispheres  were 
the  seats  of  the  softening,  which  involved  the  gray  matter  only. 

Thrombosis  of  the  veins  or  sinuses  may  also  in  general  terms  be 
produced  by  whatever  cause  is  capable  of  retarding  the  current  of 
blood.  Mr.  Toynbee,2  in  his  chapter  on  diseases  of  the  mastoid  cells, 
has  brought  forward  several  cases  in  which  the  lateral  sinus  was  occluded 
by  coagula,  and  in  which  there  was  cerebral  softening. 

Cerebral  softening  may  also  result  from  the  formation  of  adven- 
titious growths,  or  from  the  presence  of  foreign  bodies  in  the  brain. 
In  such  cases  the  process  begins  with  inflammation,  and  is  similar  to 
the  action  which  sometimes  goes  on  around  an  extravasation  of  blood. 

Acute  cerebritis  or  meningitis  may  likewise  result  in  softening. 
This  fact  is  admitted  by  Drs.  Russell  Reynolds  and  Bastian,  in  their 
admirable  essays  on  cerebritis  and  softening  of  the  brain,  though  with 
evident  reluctance. 

We  see,  therefore,  that  cerebral  softening  may  be  caused  either  by 
anaemia  or  inflammation,  and  that  it  is  of  two  kinds,  inflammatory  and 

1  Journal  de  medecine  de  Lyon,  Fdvrier,  1867. 

9  "Tne  Diseases  of  the  Ear,  their  Nature,  Diagnosis,  and  Treatment,"  London,  1860. 


CEREBRAL   SOFTENING.  175 

non-inflammatory.  The  seat  of  the  softening  may  be  in  any  part  of  the 
brain,  although  some  regions  are  more  liable  than  others.  When  due 
to  thrombosis,  there  appears  to  be  no  predilection  for  any  particular 
location,  but,  as  embolism  is  generally  found  on  the  left  side  in  the 
middle  cerebral  artery,  the  parts  of  the  brain  supplied  by  this  vessel 
are  more  liable  than  the  corresponding  parts  of  the  right  side. 

Durand-Fardel,  however,  did  not  arrive  at  this  conclusion.  Of  one 
hundred  and  sixty-nine  cases  of  softening,  he  found  the  left  hemisphere 
the  seat  in  sixty-nine,  the  right  in  seventy-one,  both  in  twenty -six,  and 
the  middle  line  in  three. 

The  gray  matter  is  generally  supposed  to  be  more  frequently  the 
seat  of  softening  than  the  white.  It  is  true  that,  of  thirty-three  cases 
of  acute  softening  observed  by  Durand-Fardel,1  the  convolutions  were 
involved  in  thirty-one,  but  in  nine  only  were  they  the  sole  part  af- 
fected. 

In  fifty -three  cases  which  the  same  author  collected  from  the  writ- 
ings of  Rostan,  Lallemand,  and  others,  the  centres  of  softening  were 
found  to  be  as  stated  in  the  following  table.  Occasionally  more  than 
Dne  region  was  involved. 

Convolutions  and  white  substance 22 

Convolutions  alone 6 

White  substance  alone 5 

Corpus  striatum  an<l  optic  thalamus G 

Corpus  striatum  alone 11 

Optic  thalamus  alone 4 

Pons  Varolii 3 

Crux  cerebri 1 

Corpus  callosum 1 

Walls  of  tii'-  ventricles  (septum) * 1 

Fornix 1 

Cerebellum 1 

Rostan,  on  th"  other  hand,  found  tin.'  corpora  striata  and  the  optio 
titfclttmi  to  be  the  parts  most  frequently  affected,  and  after  these  the 
centred  part  of  tint  hemispheres,  lie  met  with  bul  few  oases  involving 
the  median  line. 

As  regards  the  frequency  with  which  the  convolutions  with  the 
white  substance  were  involved,  as  compared  with  the  motor  tract,  he 
found  that,  of  one  hundred  and  seventy-seven  cases  of  acute  and 
chronic  softening,  the  convolutions  and  white  substance  were  affected 

in    one  hundred  and  nineteen,  and  the  corpora  striata  and  optic  thalami 

in  fifty  eight. 

middle  lobe  IS  more  liable  than  any  other,  as  is  Been  in  tin-  fol- 
lowing statement  of  Durand-Fardel,  based  upon  an  analysis  of  ninety- 
five  cas.  >>: 

1  "Traite  du  ramoWsaemeQl  da  oerreau,"  Puis,  1813. 


176  DISEASES   OF   THE   BKAIN. 

Posterior  lobe 18 

Middle 61 

Anterior 13 

Posterior  and  middle 1 

Posterior  and  anterior 2 

Middle  and  anterior 2 

Whole  convexity  of  hemisphere 1 

Middle  line 1 

Tn  more  than  one-half  of  the  cases,  therefore,  the  middle  lobe  was 
th3  seat  of  the  disease. 

A  question  connected  with  the  pathology  of  cerebral  softening,  as 
with  haemorrhage,  is,  "  Can  we  determine,  from  a  consideration  of  the 
symptoms,  what  part  of  the  brain  is  the  seat  of  the  lesion  ? "  The 
answer  must  be  the  same.  We  can  do  so  with  some  approach  to  ac- 
curacy, but,  till  we  are  better  acquainted  with  the  physiology  of  the 
different  ganglia  composing  the  brain,  we  cannot  expect  to  do  so  with 
absolute  certainty.  Indeed,  owing  to  the  greater  extent  of  tissue  in- 
volved, compared  to  that  affected  in  haemorrhage,  we  have  a  more  com- 
plicated set  of  phenomena  to  deal  with.  I  have  nothing  further  to 
add  to  the  remarks  made  on  a  similar  point,  under  the  head  of  cerebral 
haemorrhage. 

Treatment. — The  treatment  proper  for  cerebral  softening  should  de- 
pend very  much  upon  the  cause  from  which  it  has  arisen,  and  must 
more  or  less  be  directed  against  the  symptoms  which  are  manifested. 
Thus,  if  there  is  reason  to  suspect  the  existence  of  thrombosis  or  embo- 
lism, and  a  consequent  anaemic  condition  of  a  portion  of  the  brain,  the 
judicious  use  of  stimulants  and  tonics  is  advisable,  while  the  body  should 
be  kept  warm  by  additional  clothing,  or  the  application  of  artificial 
heat — at  the  same  time  the  recumbent  posture  should  be  assumed,  and 
the  head  supported  on  a  low  pillow.  Mental  exertion  should,  of  course, 
be  absolutely  interdicted.  If  there  be  much  headache,  it  is  probably 
due  to  too  great  an  activity  of  the  collateral  circulation,  and  in  such  a 
case  some  one  of  the  bromides  may  be  given  in  large  doses,  repeated  as 
often  as  may  be  necessary.  I  have  frequently  seen  great  relief  follow 
their  administration. 

Delirium  is  often  due  to  a  like  cause  and  may  be  similarly  treated. 
Dr.  Reynolds '  speaks  highly  of  the  Indian  hemp  in  doses  of  a  quarter 
to  half  a  grain  of  the  extract;  but  I  have  found  the  bromide  of  potas- 
sium, in  doses  of  thirty  grains  every  three  or  four  hours,  more  effica- 
cious. It  is  also  the  most  beneficial  remedy  in  the  convulsions  which 
frequently  precede  a  fatal  termination. 

In  that  form  of  softening  which  is  obscure  in  its  origin  and  gradual 
in  its  progress,  there  is  a  little  more  hope  of  a  favorable  result,  though 
even  here  it  must   be  confessed  that  treatment  is  not  often  effectual. 

1  Article,  "  Softening  of  the  Brain,"  in  "  System  of  Medicine,"  vol.  ii. 


CEREBRAL   SOFTENING.  177 

Still,  as  I  have  said,  when  speaking  of  the  prognosis,  there  are  un- 
doubtedly cases  in  which  recovery  has  taken  place,  and  I  am  very  sure 
that  I  have  several  times  succeeded  in  curing  individuals  who,  so  far  as 
I  have  been  able  to  judge,  were  affected  with  cerebral  softening.  As 
these  cases  are  interesting  in  themselves,  and  as  the  histories  will  show 
the  means  of  treatment  employed,  I  do  not  hesitate  to  transcribe  the  fol- 
lowing typical  ones  from  my  case-book: 

I. — Mr.  R.,  a  gentleman,  twenty-four  years  of  age,  awoke  one  morn 
ing  about  the  middle  of  March,  1870,  with  a  sensation  of  numbness  ex 
tending  through  the  whole  of  the  left  arm  and  leg,  and  with  a  feeling 
of  vertigo  which  was  insupportable  when  he  arose  from  the  bed.  He 
sat  down  in  a  chair,  and  while  in  this  position  was  conscious  of  a  buzz- 
ing sound  in  the  right  ear.  In  the  course  of  half  an  hour  the  vertigo 
passed  off,  but  the  numbness  and  sound  in  the  ear  remained,  and  he  oc- 
casionally saw  double.  In  a  few  days  afterward  he  noticed  a  slight 
difficulty  of  articulation,  owing  to  apparent  thickness  of  the  tongue,  and 
about  the  same  time  observed  that  in  the  morning  the  pillow  was  wet 
with  the  saliva  which  had  run  from  his  mouth  during  sleep.  His  uncle, 
a  wealthy  gentleman  of  this  city,  sent  him  off  traveling,  but  he  returned 
in  a  few  weeks  with  loss  of  power  in  the  left  arm  and  leg,  which  had  be- 
gun to  be  manifested  to  a  slight  extent  before  his  departure.  He  came 
under  my  charge  May  15,  1870. 

At  this  time  the  paralysis,  of  both  motion  and  sensation,  was  well 
marked  on  the  left  side,  as  shown  by  the  aesthesiometcr  and  dynamom- 
eter. The  line  made  by  the  dynamograph  with  the  right  hand  was 
perfectly  straight,  while  that  made  by  the  left  was  at  an  angle  of  forty- 
five  degrees  with  the  other.  In  his  conversation  he  clipped  his  words, 
and  sometimes  left  out  the  smaller  ones.  His  memory  he  stated  was 
materially  impaired.  There  was  almost  constant  headache  over  the 
whole  frontal  region,  and  attacks  of  vertigo  were  frequent.  There  was 
no  marked  paralysis  of  the  face,  though  the  muscles  of  both  sides  were 
paretic,  and  he  often  had  double  vision.  The  right  pupil  was  Ian 
dilated  and  w&a  insensible  to  light. 

( )|)lithaltnoscopic  examination  showed  the  left  eye  to  be  perfectly 
normal,  but  the  retinal  vessels  of  the  right  were  smaller  and  straight, 
and  the  choroid  was  paler  than  natural. 

Upon  inquiry  I  asoertained  thai  he  bad  given  extraordinary  atten- 
tion to  his  business  for  a  period  of  several  months  before  the  attack  of 
numbness,  frequently  being  up  making  calculations  till  three  o'clock  in 
the  morning,  and  thus   depriving  himself  of   the  necessary  amoui 

sleep. 

My  opinion  was,  that    he  was   suffering    from    incipient    softening  oi 
the  brain  due  to  disease  of  the  capillaries,  which,  in    its  turn,  resulted 
from  cerebral  congestion  and  exhaustion,      1  was  further  of  the  opinion 
that  the  lesion  involved  the  righl  hemisphere  and  motor  tract. 
13 


178  DISEASES   OF   TIIE   BRAIN. 

I  prescribed  the  phosphide  of  zinc  in  the  dose  of  the  tenth  of  a 
grain,  with  half  a  grain  of  extract  of  nux-vomica  in  pill  three  times  a 
day,  with  the  constant  galvanic  current  three  times  a  week,  the  latter 
to  be  derived  from  fifteen  of  Smee's  cells,  and  to  be  passed  from  fore- 
head to  occiput  for  three  or  four  minutes  at  a  time.  At  the  end  oi  ten 
days  he  had  lost  his  diplopia,  the  pupil  of  the  right  eye  had  regained 
its  natural  diameter  and  irritability,  and  the  vertigo  and  headache  had 
notably  diminished.  The  treatment  was  continued,  and  at  the  end  of 
a  month  he  had  recovered  the  sensibility  and  power  on  the  paralyzed 
side  to  such  an  extent,  and  had  improved  so  much  in  other  respects, 
that  I  advised  him  to  take  a  short  journey.  He  was  absent  two  weeks, 
during  which  period  he  continued  to  take  the  pills  as  before,  and  on 
his  return  was,  to  all  appearance,  well.  He  has  since  remained  in  ex- 
cellent health. 

H. — Mr.  R.  W.,  a  merchant  of  this  city,  consulted  me  in  April,  1868, 
under  the  following  circumstances : 

After  a  long  period  of  great  domestic  anxiety,  during  which  he  had 
been  engaged  in  some  heavy  commercial  transactions,  and  had  suffered 
from  wakefulness,  he  experienced  one  afternoon,  while  riding  in  the 
park  in  his  carriage,  a  slight  quivering  motion  at  the  apex  of  the  tongue. 
It  continued  until  he  reached  home;  and  then,  upon  looking  in  a  mir- 
ror, he  could  see  the  fibrillary  movement  very  distinctly.  He  was  not 
alarmed,  and  went  to  bed  at  his  usual  hour.  In  the  morning  he  noticed 
a  little  thickness  of  speech,  but  the  movement  had  ceased.  That  after- 
noon he  had  a  violent  headache,  attended  with  vertigo  and  nausea.  Be- 
coming alarmed,  he  sent  for  his  family  physician,  who  ascribed  the 
symptoms  to  indigestion,  and  administered  a  mild  cathartic.  The  fol- 
lowing day,  on  attempting  to  rise  from  the  bed  to  go  to  the  water- 
closet,  he  was  attacked  with  such  a  severe  vertigo  that  he  was  obliged 
to  lie  down  again;  and,  though  he  did  not  for  a  moment  lose  conscious- 
ness, his  faeces  escaped  from  him  involuntarily.  From  this  time  he 
gradually  lost  strength  in  both  arms  and  legs,  and  his  speech  became 
very  defective.  His  memory  suffered  to  such  an  extent  that  he  forgot 
the  names  of  his  children.  There  was  very  little  headache,  the  vertigo 
had  ceased,  there  was  no  disturbance  of  vision,  and  no  loss  of  power 
over  the  sphincters.  About  six  weeks  after  the  occurrence  of  the  first 
symptom  noticed,  he  came  under  my  care. 

At  this  time  there  was  anaesthesia  of  both  sides  of  the  body,  both 
legs  and  both  arms  had  lost  power;  he  clipped  his  words,  and  frequently 
substituted  others  of  similar  sound  or  meaning  for  those  he  ought  to 
have  used.  His  memory  was  much  weakened,  and  there  was  a  strong 
tendency  to  stupor.  There  were  no  troubles  of  the  special  senses — 
ophthalmoscopic  examination  revealed  nothing  abnormal — there  was  no 
facial  paralysis.  I  diagnosticated  softening  of  the  brain  from  general 
cerebral  amemia  consequent  upon  congestion  and  cerebral  exhaustion, 


CEREBRAL   SOFTENING.  179 

and  I  prescribed  a  liberal  allowance  of  wine,  a  full  and  nutritious  diet, 
carriage  exercise,  and  amusements  of  various  kinds.  This  was  the  very 
reverse  of  the  treatment  to  which  he  had  been  subjected.  In  addition, 
I  recommended  the  constant  galvanic  current,  to  be  applied  as  in  the 
previous  case,  and  gave  the  following  prescription:  IJ.  Olei  phosphorat. 
|  ss;  mucil.  acaciae,  5J;  ol.  bergamii,  gtt.  xv.  M.  ft.  emulsio.  Dose, 
gtt.  xv.  ter  die. 

The  treatment  was  carried  out  with  the  result  of  obtaining  a  gradual 
and  permanent  improvement,  so  that  at  the  end  of  about  six  months 
the  patient  was  well.  He  then  went  to  Europe,  where  he  now  is,  with 
as  good  health  as  he  has  ever  enjoyed. 

Other  cases,  similar  in  their  general  features,  have  been  under  my 
care  with  a  like  result  in  each,  and  several  others  have  been  very  decid- 
edly improved  and  relieved  of  the  more  prominent  symptoms  of  the 
disease,  without,  however,  regaining  full  health.  The  means  of  treat- 
ment thus  far  consist  in  the  use  of  tonics,  stimulants,  and  especially 
phosphorus  and  strychnine,  the  avoidance  of  all  severe  mental  exertion, 
and  all  excessive  emotion,  open-air  exercise,  and  the  use  of  the  constant 
galvanic  current. 

The  beneficial  effects  of  maintaining  the  physical  strength  were 
several  years  since  pointed  out  by  Mr.  F.  Skey '  in  a  clinical  lect- 
ure delivered  at  St.  Bartholomew's  Hospital,  but  it  must  be  con- 
fessed that  the  opposite  plan  of  treatment  has  been  very  generally 
followed. 

Softening  from  the  effects  of  thrombosis  or  embolism  is,  as  I  have 
sail,  not  much  under  the  control  of  the  physician.  Patients  recover 
from  it,  however,  when  they  are  of  good  constitution,  and  when  the 

IS  of  softening  has  not  boon  extensive.  The  mind  and  body  may, 
and  in  such  cases  generally  do,  remain  feeble,  and  we  arc  therefore 
lilted  for  the  relief  of  the  condition.  In  such  cases  tonics,  and 
among  them  phosphorus,  strychnine,  and  wine,  occupy  a  prominent 
place;  the  constant  galvanic  current  to  the  head,  and  the  induced  to 
the  paralyzed  muscles,  will  rarely  fail  to  be  of  service. 

III.  Thus  a  gentleman,  who  had  been  a  distinguished  officer  of  the 
army,  suffered  from  loss  of  memory,  defective  articulation,  •  able 

vision,  and  right  hemiplegia,  probably  the  result  of  embolism.  Several 
years  before  he  came  under  my  oharge,  he  had  been  treated  by  Dr.  J. 
T.  Metcalfe,  for  heart-disease,  the  result  of  acute  rheumatism.  1 
the  phosphide  of  zinc  and  extraot  of  nux-vomioa  aooording  to  the 
mula  previously  mentioned,  advised  a  liberal  use  of  wine  and  beef* 
steaks,  applied  the  primary  current  to  the  brain,  and  the  induced  cur- 
rent to  his  paralyzed  arm  and  leg,  and  in  a  few  weeks  had  the  satisfac- 
tion of  seeing  such  a  degree  of  improvement  as  almost   to  constitute  a 

1  "On  the  Value  of  Tonic  Treatment  in  some  Diseases  of  tin'  Brain,  more  especially 
C  '  Ramollissement,"  Dublin  Hospital  Qautte,  November,  1- 


180  DISEASES  OF   THE   BRAIN. 

cure.  The  ocular  troubles  had  disappeared,  his  memory  had  improved, 
he  talked  as  well  as  ever,  and  the  numbness  and  loss  of  strength  were 
no  longer  remarked  unless  he  over-exerted  himself,  which,  owing  to  his 
general  feeling  of  Men  aise,  he  was  very  apt  to  do.  He  remained  in 
this  condition  for  over  a  year,  when  he  had  several  other  attacks  of 
embolism,  each  of  which  left  him  more  weak,  mentally  and  physically, 
than  before,  and  of  which  he  eventually  died. 

There  were  some  interesting  features  connected  with  this  case, 
which  will  be  referred  to  at  greater  length  under  the  head  of 
aphasia. 

IV. — In  another  case,  in  which  there  was  reason  to  think  a,  foyer 
of  softening  had  been  absorbed,  a  marked  relief  from  the  sequelae  was 
obtained.  The  patient,  a  literary  gentleman  of  distinction,  had,  several 
years  previously  to  my  seeing  him,  suffered  from  an  attack  of  acute 
rheumatism  with  endocarditis.  About  a  month  after  his  recovery,  as 
he  was  sitting  in  his  library  before  the  fire,  he  felt  a  sensation  as  if  one 
side  of  his  face  had  suddenly  become  much  heavier  than  the  other.  Al* 
most  immediately  afterward  he  lost  consciousness,  and  fell  to  the  floor. 
He  could  not  have  been  in  this  condition  longer  than  five  minutes 
when  he  came  to  himself,  to  find  that  he  was  paralyzed  in  the  right 
arm  and  leg.  Attempting  to  call  for  assistance,  he  found  he  could 
not  articulate.  His  wife  soon  afterward  entered  the  room,  and  medical 
aid  was  obtained.  He  was  bled  to  the  extent  of  sixteen  ounces,  and 
purged  with  croton-oil. 

The  following  day  he  was  much  better;  could  move  his  arm  and 
leg,  and  articulate  with  some  degree  of  distinctness,  but  toward  even- 
ing headache  ensued,  he  became  delirious,  and  the  paralysis  increased. 
Of  the  condition  immediately  following,  he  could  give  no  very  clear 
account.  He  only  knew  that  he  was  confined  to  his  bed  for  several 
weeks,  was  delirious  part  of  the  time,  and  that,  after  the  acute  attack 
passed  off,  he  was  left  with  an  enfeebled  mind,  imperfect  articulation, 
and  paralysis  of  the  arm  and  leg  on  the  right  side.  He  went  to 
Europe,  traveled  extensively,  and  returned  at  the  end  of  a  year  very 
much  improved,  but  still  with  some  degree  of  mental  weakness, 
defective  speech,  and  paralysis,  remaining. 

When  he  came  under  my  observation,  the  following  were  the  prin- 
cipal symptoms  observed:  The  strength  of  the  right  arm,  as  measured 
with  the  dynamometer,  was  not  one-third  that  of  the  left;  the  exten- 
sors of  the  leg  and  foot  were  almost  entirely  paralyzed,  so  that  in 
walking  he  abducted  the  leg  so  as  to  cause  the  foot  to  clear  the 
ground  ;  electro-muscular  contractility  was  much  weakened,  though 
the  induced  •  current  caused  feeble  contractions.  His  speech  was  af- 
fected mainly  as  regarded  the  memory  of  words.  He  spoke  with  a 
good  deal  of  volubility,  but  constantly  used  the  wrong  expressions. 
Thus,  when  he  wished  to  tell  me  that  he  had  visited  Europe  for  the 


CEREBRAL   SOFTENING.  181 

benefit  of  his  health,  he  said  :  "  I  went  to  Elope  for  the  bequest  of  my 
hedge,"  and  then  went  on — continually  making  other  mistakes — to  tell 
me  a  long  story  which  I  could  scarcely  understand.  His  emotions 
were  easily  disturbed:  he  cried  because  he  had  to  wait  a  few  minutes 
in  my  reception-room  before  seeing  me. 

Ophthalmoscopic  examination  showed  pale  choroids  and  straight 
and  attenuated  retinal  vessels.  Auscultation  revealed  the  existence 
of  both  mitral  and  aortic  regurgitation. 

Taking  into  consideration  the  history  of  the  case  and  the  present 
condition  of  the  patient,  I  diagnosticated  embolism  of  the  left  middle 
cerebral  artery,  subsequent  softening  and  eventual  absorption  of  the 
diseased  part  of  the  brain.  My  idea  was  that  the  brain,  as  a  whole, 
was  anaemic,  and  that,  with  improved  nutrition  of  it  and  the  paralyzed 
limbs,  amelioration  of  the  symptoms  was  possible. 

I  therefore  prescribed  the  phosphide  of  zinc  and  nux-vomica  pills 
as  before  mentioned,  directed  the  use  of  wine  to  the  extent  of  half  a 
bottle  of  champagne  daily,  and  advised  that  animal  food  should  form 
the  principal  portion  of  each  meal.  Since  his  illness  he  had,  by  direc- 
tion of  his  physician,  left  off  the  use  of  coffee.  I  directed  it  to  be 
resumed,  and  to  be  taken  strong.  The  primary  galvanic  current  was 
passed  through  the  head  in  the  manner  previously  indicated  in  this 
chapter,  and  the  induced  current  was  applied  for  half  an  hour  three 
times  a  week  to  the  arm  and  leg,  each  paralyzed  muscle  receiving  a 
full  share  of  attention. 

It  was  not  long  before  signs  of  amendment  were  noticed.  His 
strength  became  greater  in  the  arm,  and  he  was  able  to  extend  the  leg 
and  to  raise  the  foot  after  half  a  dozen  electrical  applications.  His 
speech  next  gave  evidence  of  improvement,  and  his  mind  became 
stronger.  The  treatment  was  continued  for  about  four  months,  with 
only  an  intermission  of  a  week.  At  the  end  of  that  time  his  gait  was 
almost  natural,  though  he  still  swung  the  foot  a  very  little,  his  arm 
was  nearly  as  strong  as  the  other,  his  mind  was  not  perceptibly  weaker 
than  that  of  other  persons  of  his  age  (fifty-five),  and  his  speech  was 
excellent  except  when  he  was  excited  and  very  anxious  to  express 
himself  correctly  and  fluently. 

There  La  one  point  in  regard  <o  whieh  a  few  words  are  perhaps 
necessary,  and  that  La  to  enter  a  protest  against  the  use  of  counter- 
irritation  of  any  kind,  and  to  disoountenanoe,  as  far  as  1  can,  the  em- 
ployment of  the  actual  cautery.    I  have  never  seen  the  least  advant 
follow  the  application  of  oroton-oil  to  the  shaven  soalp,  nor  can  I 

ha  measure  can  be  reoommended  on  rational  grounds. 
I  have  several  times  witnessed  its  action,  and1  have  invariably  Been  it 
aggravate  the  symptoms.  In  the  case  of  a  gentleman  from  St,  Louis, 
affected  with  oerebral  softening,  the  effect  was  to  make  his  speech 
still  more  Imperfect  and  bis  mind  weaker.     A  Lady,  who  was  affected 


182  DISEASES  OF  THE   BRAIN. 

■with  all  the  more  prominent  symptoms  of  softening  of  the  brain,  bid 
all  the  phenomena  increased  in  violence  after  the  application  of  the 
actual  cautery  to  the  nape  of  the  neck.  I  could  easily  adduce  otncr 
examples  to  the  same  effect,  were  it  necessary. 


CHAPTER  VII. 

APHASIA. 


The  subject  of  aphasia  is  of  such  interest,  and  so  much  attention 
has  recently  been  given  to  it  by  physiologists  and  pathologists,  that, 
although  it  is  only  a  symptom  common  to  several  morbid  conditions, 
a  treatise  on  diseases  of  the  nervous  system  would  scarcely  be  re- 
garded as  complete  without  its  being  fully  considered. 

By  aphasia  is  understood  a  condition  produced  by  an  affection  of 
the  brain  by  which  the  idea  of  language,  or  of  its  expression,  is  im- 
paired. The  word  is  derived  from  the  Greek — a,  privative,  and  <paatg, 
speech — and,  as  stated  by  Trousseau,  was  proposed  by  M.  Chrysaphis, 
a  distinguished  Greek  scholar,  as  a  substitute  for  alalia,  used  by  Lor- 
dat,  and  aphonia,  employed  by  Broca,  to  designate  the  same  condition. 

In  the  definition  which  I  have  given  of  aphasia,  the  term  is  limited 
to  impairment  of  the  idea  of  language  or  of  its  expression.  It  does 
not,  therefore,  include  those  cases  in  which  the  individuals  are  able  to 
speak,  but  will  not  ;  such  as  are  met  with  among  the  insane.  The  idea 
of  language  is  as  perfect  as  ever,  and  is  doubtless  entertained,  but  the 
person  does  not  speak  because  he  does  not  will  to  do  so,  and  this  fail- 
ure may  arise  either  from  a  lack  of  the  necessary  power,  or  from  a 
stubborn  determination  not  to  speak.  A  lady  was  a  short  time  since 
under  my  charge  who  had  been  treated  by  a  homoeopathic  physician 
as  a  case  of  aphasia.  A  very  slight  examination  was  sufficient  to  con- 
vince me  that  the  case  was  one  of  hysteria.  She  had  not  spoken  for 
several  months,  but  upon  one  occasion  she  came  to  my  office  with  her 
maid,  whom  she  required  to  repeat  the  alphabet,  and  when  the  right 
letter  was  reached  she  signified  the  fact  by  raising  her  hand.  She  thus 
spelled  out  the  words  she  wished  to  use.  Subsequently  she  procured  a 
card  with  all  the  letters  on  it,  such  as  are  used  for  children  learning 
their  alphabet,  and  she  composed  her  words  from  this.  Of  course  all 
these  facts  showed  that  her  idea  of  language  was  intact,  but  she  still 
might  have  lost  the  power  of  coordinating  the  muscles  concerned  in 
articulation  so  as  to  express  herself  in  spoken  words.  Although  I  was 
sure  this  was  not  the  case,  I  failed  to  make  her  speak,  until  one  morn- 
ing she  became  very  much  interested  in  something  I  was  saying,  and, 
finding  her  alphabet  too  slow  a  means  of  expression,  dropped  it  and 


APHASIA.  183 

began  to  speak  with  great  fluency.  After  talking  with  energy  for  a 
quarter  of  an  hour,  she  suddenly  recollected  herself  and  took  up  her 
card  of  letters  again,  but  the  charm  was  broken,  and  by  degrees  she 
resumed  her  speech.  At  one  time  this  lady  was  under  the  care  of  my 
friend  Prof.  Flint,  for  some  chest  or  throat  difficulty,  and  on  one  occa- 
sion spoke  very  well. 

Neither  does  aphasia  embrace  cases  of  inability  to  speak  from  paral- 
ysis of  the  tongue  or  other  muscles  of  articulation^  Defective  speech 
from  this  cause  is  frequently  met  with  in  hemiplegia,  in  glosso-labio- 
laryngeal  paralysis,  and  some  other  affections.  In  such  instances  the 
idea  of  language  remains,  but  the  patient  does  not  speak  because  he  is 
unable  to  put  the  organs  of  articulation  in  motion.  A  few  days  ago  a 
gentleman,  a  prominent  merchant  of  the  city,  was  sent  to  me  as  a  case 
of  aphasia.  As  he  entered  my  consulting-room,  I  saw  that  he  was 
hemiplegic  on  the  left  side,  and,  on  telling  him  to  put  out  his  tongue, 
found  that  he  could  not  get  it  beyond  the  teeth,  or  touch  the  roof  of 
his  mouth  with  it.  The  history  of  the  case  was  that  of  ordinary  cere- 
bral haemorrhage,  and  he  regained  the  power  of  speaking  after  several 
applications  of  the  primary  and  induced  galvanic  currents  had  been  made 
to  the  tongue  and  muscles  of  the  face. 

The  distinction  between  aphonia  and  aphasia  must  also  be  made.  In 
the  one  the  idea  of  speech  is  undisturbed,  and  articulation  is  not  inter- 
fered with  except  as  regards  phonation.  Aphonic  patients  can  whisper, 
but  are  unable  to  speak  in  full  voice,  owing  to  some  laryngeal  affection 
impairing  the  tone  of  the  vocal  chords. 

The  fact  that  the  faculty  of  speech  may  be  deranged  independently 
either  of  the  will,  paralysis,  or  loss  of  voice,  appears  to  have  been 
noticed  at  a  very  early  period  in  the  progress  of  science.  Thus  Isaiah1 
Bays,  "  For  with  stammering  lips  and  another  tongue  will  he  speak  to 
tins  people;"  and  again,1  "Thou  shalt  not  see  a  fierce  people,  a  people 
of  a  deeper  speech  than  thou  canst  perceive;  of  a  stammering  tongue 
lli.it  thou  canst  not  understand." 

Thucydidcs  mentions  that  many,  who  suffered  from  the  plague  which 
i  at  Athens,  found  on  |g  that   they  had    not  only  forgotten 

(he  names  of  their  friends  and  relations,  lmt  also  their  own  nam 
Pliny,1  in  the  chapter  entitled   Memori  p/or,  says,  in  i 

T  this  faculty :    "For  nothing  is  so  weak  in  man;  i  fills, 

injuries,  oven  a  fright,  may  impair  it  partially,  or  destroy   it    altogether. 

>w  from  a  ston  i  has  :i  1 .  .! ; di- ■« i  the  memory  of  the  alphab  t.     A  fall 

from  a  high  roof  has  caused  a  man  i  La  mother  and 

bbors,  another  even  forgol   his  slaves,  and   Messala  Corvinus,  the 

Orator,  could  not   recall  his  own  nam 

1  Chapter  xxviii.,  11.  s  Chapter  ixxlii.,  19.  *  Lib.  \ii ,  cap..xxrr. 

*  Trousseau  has  translated  this  i  omewhat  differently.     I  quot<    from  sm  illu- 

Bamated  copy  printed  at  I  (Treviso),  in  October,  1479. 


184  DISEASES   OF  THE   BRAIN. 

Suetonius  ,  relates  that  Claudius  so  far  lost  his  memory  that  he  for- 
got the  names  of  persons  to  whom  he  desired  to  speak,  and  could  not 
even  recollect  the  words  he  wished  to  use. 

Passing  over  several  authors  of  later  times  who  have  recognized  the  ( 
existence  of  the  difficulty  in  question,  we  come  to  Crichton,2  who  re- 
marks as  follows :  "  There  is  a  very  singular  defect  in  memory,  of  which 
I  have  myself  seen  two  remarkable  instances.  It  ought  rather  to  be 
considered  as  a  defect  of  that  principle  by  which  ideas  and  their  proper 
expressions  are  associated,  than  of  memory,  for  it  consists  in  this,  that 
the  person,  although  he  has  a  distinct  notion  of  what  he  means  to  say, 
cannot  produce  the  words  which  ought  to  characterize  his  thoughts. 
The  first  case  of  this  kind  which  occurred  to  me  in  practice  was  that  of 
an  attorney  much  respected  for  his  integrity  and  talents,  but  who  had 
many  sad  failings  to  which  our  physical  nature  too  often  subjects  us. 
Although  nearly  in  his  seventieth  year,  and  married  to  an  amiable  lady 
much  younger  than  himself,  he  kept  a  mistress,  whom  he  was  in  the 
habit  of  visiting  every  evening.  The  arms  of  Venus  are  not  wielded 
with  impunity  at  the  age  of  seventy.  He  was  suddenly  seized  with 
great  prostration  of  strength,  giddiness,  forgetfulness,  insensibility  to  all 
concerns  of  life,  and  every  symptom  of  approaching  fatuity.  His  for- 
getfulness was  of  the  kind  alluded  to.  When  he  wished  to  ask  for  any 
thing,  he  constantly  made  use  of  some  inappropriate  term.  Instead  of 
asking  for  a  piece  of  bread,  he  would-  probably  ask  for  his  boots  ;  but, 
if  these  were  brought,  he  knew  they  did  not  correspond  with  the  idea 
he  had  of  the  thing  he  wished  to  have,  and  was  therefore  angry.  Yet 
he  would  still  demand  some  of  his  boots  and  shoes,  meaning  bread.  If 
he  wanted  a  tumbler  to  drink  out  of,  it  was  a  thousand  to  one  he  did 
not  call  for  a  certain  chamber-utensil,  and,  if  it  was  the  said  utensil  he 
wanted,  he  would  call  it  a  tumbler  or  a  dish.  He  evidently  was  con- 
scious that  he  pronounced  wrong  words,  for,  when  the  proper  expres- 
sions were  spoken  by  another  person,  and  he  was  asked  if  it  were  not 
such  a  thing  he  wanted,  he  always  seemed  aware  of  his  mistake,  and  cor- 
rected himself  by  adopting  the  appropriate  expression.  This  gentleman 
was  cured  of  the  complaint  by  large  doses  of  valerian  and  other  proper 
medicines." 

Dr.  Crichton  subsequently  met  with  another  case  similar  to  the  fore- 
going, and  he  quotes  the  following  from  Prof.  Gruner,  of  Jena,  in  vol. 
vii.  of  the  Psychological  Magazine.  The  patient,  a  learned  gentleman, 
after  his  recovery  from  an  acute  fever,  suffered  a  loss  of  memory  for 
words.  Among  the  first  things  he  desired  to  have  was  coffee  (Jcaffee), 
but,  instead  of  pronouncing  the  letter/*,  he  substituted  in  its  place  a  s, 

1  "  C.  Suetonii  Tranquilli,"  xii.  Caesares. 

3  "Aii  Inquiry  into  the  Nature  and  Origin  of  Mental  Derangement,  comprehending  a 
Concise  System  of  the  Physiology  and  Pathology  of  the  Human  Mind,  and  a  History  of 
the  Passions  and  their  Effects,"  London,  1798,  vol.  i.,  p.  371. 


APHASIA.  185 

and  therefore"  asked  for  a  cat  (Jcatze).  In  every  word  which  had  an/* he 
committed  a  similar  mistake,  substituting  a  z  for  it. 

He  also  cites,  from  Van  Goens,  the  case  of  Madame  Hennert,  wife 
of  the  professor  of  mathematics  at  Utrecht,  who  suffered  a  similar  de- 
fect of  memory.  When  she  wished  to  ask  for  a  chair  she  asked  for  a 
table,  and  when  she  wanted  a  book  she  demanded  a  glass.  But,  what 
was  singular  in  her  case  was,  that  when  the  proper  expression  of  her 
thought  was  mentioned  to  her,  she  could  not  pronounce  it. 

She  was  angry  if  people  brought  her  the  thing  she  had  named  in- 
stead of  the  thing  she  desired.  Sometimes  she  herself  discovered  that 
she  had  given  a  wrong  name  to  her  thoughts.  This  complaint  continued 
several  months,  after  which  she  gradually  recovered  the  right  use  of  her 
recollection.  It  was  only  in  this  particular  point  that  her  memory 
seemed  to  be  defective,  for  M.  Van  Goens  assures  us  that  she  con- 
ducted her  household  affairs  with  as  much  regularity  as  she  ever  had 
done,  and  that  she  used  to  show  her  husband  the  situation  of  the  heavens 
on  a  map  with  as  much  accuracy  as  when  she  was  in  perfect  health. 

The  following  case,  in  Gesner's  Entdeckuufjcn  Oxr  Keuesten  Ztlt  in 
der  Arzneigelehrheit,  is  likewise  quoted  by  Crichton: 

"  A  man,  aged  seventy,  was  seized,  about  the  beginning  of  January, 
with  a  kind  of  cramp  in  the  muscles  of  the  mouth,  accompanied  with  a 
sense  of  tickling  all  over  the  surface  of  the  body,  as  if  ants  were  creep- 
ing over  it.  On  the  20th  of  the  same  month,  after  having  experienced 
an  attack  of  giddiness  and  confusion  of  ideas,  a  remarkable  alteration 
of  his  speech  was  observed  to  have  taken  place.  He  articulated  easily 
and  fluently,  but  made  use  of  strange  words,  which  nobody  understood. 
The  number  of  these  does  not  at  present  seem  to  be  great,  but  they  are 
frequently  repeated.  Some  of  them  he  seems  to  forget  entirely,  and 
then  new  ones  arc  formed.  When  he  speaks  quick  he  sometimes  pro- 
nounces numbers,  and  now  and  then  he  employs  common  words  in  their 
proper  sense.  He  is  conscious  that  he  speaks  nonsense.  What  ho 
writes  is  equally  faulty  with  what  he  speaks.  He  cannot  write  his  nam.'. 
The  words  he  writes  arc  those  he  speaks,  and  they  are'  always  written 
conformably  to  his  manner  of  pronouncing  them.  lie  cannot  read,  and 
yet  many  external  objects  seem  to  awaken  in  him  the  idea  of  their 
presence." 

])r.  Rush,'  in  (he  work  the  title  of  which  is  cited  In  low,  in  chapter  xii., 
which  treats  of  Derangement  in  tin  Memoryi  r<  Eers  so  specifically  t<> 
affections  of  the  speech  that  I  quote  his  language  \\i;!i  some  degree  of 
fullness,  and  1  do  so  with  the  less  hesitation  as  bis  observations  appear 
to  have  escaped  notice,  both  in  this  count ry  and  in  Europe.     He  se 

"  1.  There  is  .in  oblivion  of  names  and  vocables  of  all  kind-. 

";!.  There  is  an  oblivion  of  names  and  ibstitutioo 

1 "  Medical  In<  as  upon  Diseases  of  the  Mind."     Fourth  edition. 

Philadelphia,  1880,  i>.  -7 1.     The  first  edition  was  published  in  1618. 


186  DISEASES   OF   THE   BRAIN. 

of  a  word  no  ways  related  to  them.  Thus,  I  knew  a  gentleman  afflicted 
with  this  disease,  who,  in  calling  for  a  knife,  asked  for  a  bushel  of  wheat. 

"  3.  There  is  an  oblivion  of  the  names  of  substances  in  a  vernaculai 
language,  and  a  facility  of  calling  them  by  their  proper  names  in  a  dead 
or  foreign  language.  Of  this,  Wepfer  relates  three  instances.  They 
were  all  Germans,  and  yet  they  called  the  objects  around  them  only  by 
Latin  names.  Dr.  Johnson,  when  dying,  forgot  the  words  of  the  Lord's 
prayer  in  English,  but  attempted  to  repeat  them  in  Latin.  Delirious 
persons,  from  this  disease  of  the  memory,  often  address  their  physicians 
in  Latin  or  in  a  foreign  tongue. 

"  4.  There  is  an  oblivion  of  all  foreign  and  acquired  languages,  and 
a  recollection  only  of  vernacular  language.  Dr.  Scandella,  an  ingenious 
Italian,  who  visited  this  country  a  few  years  ago,  was  master  of  the 
Italian,  French,  and  English  languages.  In  the  beginning  of  the  yellow 
fever  which  terminated  his  life  in  the  city  of  New  York  in  the  autumn 
of  1798,  he  spoke  English  only  ;  in  the  middle  of  his  disease  he  spoke 
French  only;  but  on  the  day  of  his  death  he  speke  only  in  the  language 
of  his  native  country. 

"  5.  There  is  an  oblivion  of  the  sound  of  words,  but  not  of  the  let- 
ters which  compose  them.  I  have  heard  of  a  clergyman  in  Newburyport, 
who,  in  conversing  with  his  neighbors,  made  it  a  practice  to  spell  every 
word  that  he  employed  to  convey  his  ideas  to  them. 

"  6.  There  is  an  oblivion  of  the  mode  of  spelling  the  most  familiar 
words.  I  once  met  with  it  as  a  premonitory  symptom  of  palsy.  It  oc- 
curs in  old  people,  and  extends  to  an  inability,  in  some  instances,  to 
remember  any  more  of  their  names  than  their  initial  letters.  I  once  saw 
a  will  subscribed  in  this  way  by  a  man  in  the  eightieth  year  of  his  age, 
who  during  his  life  always  wrote  a  neat  and  legible  hand. 

"  9.  There  is  an  oblivion  of  names  and  ideas,  but  not  of  numbers. 
"We  had  a  citizen  of  Philadelphia  many  years  ago,  who,  in  consequence 
of  a  slight  paralytic  disease,  forgot  the  names  of  all  his  friends,  but 
could  designate  them  correctly  by  mentioning  their  ages,  with  which  he 
had  previously  made  himself  acquainted." 

Dr.  Rush  remarks  of  these  cases,  that  "  there  appears  to  be  some- 
thing like  a  palsy  of  the  mind,  quoad  these  specific  objects." 

Thus  far  there  had  been  no  attempt  to  define  with  precision  the  seat 
of  the  faculty  of  language,  or  even  to  establish  its  existence;  but,  in  the 
early  part  of  the  nineteenth  century,  Dr.  Gall,  a  German  physician,  an- 
nounced that  such  a  faculty  did  exist,  and  that  it  was  seated  in  those 
convolutions  of  the  brain  which  rest  upon  the  posterior  part  of  the 
supra-orbital  plate,  and  that  a  large  development  of  the  organ  was  indi- 
cated by  prominence  and  depression  of  the  eyes.  He  was  first  led  to 
believe  in  the  existence  of  such  an  organ  by  observing  that  some  of  the 
scholars  with  whom,  as  a  young  man,  he  had  to  compete,  excelled  him 


APHASIA.  187 

in  the  ability  to  learn  by  heart,  and  he  noticed  that  those  thus  endowed 
with  great  memory  for  words  possessed  prominent  eyes. .  From  these 
circumstances,  he  was  gradually  carried  on  to  the  foundation  of  his 
phrenological  system. 

In  reality,  however,  Gall  considered  that  there  were  two  organs  of 
language  in  each  hemisphere — the  one  originating  the  idea  of  words, 
the  other  the  talent  for  philology,  and  for  acquiring  the  spirit  of  lan- 
guages. The  former  organ  he  describes  as  lying  on  the  posterior  half 
of  the  supra-orbital  plate,  as  before  mentioned.  It  gives  a  talent  for 
learning  and  recollecting  words,  and  persons  possessing  it  large,  recite 
long  passages  by  heart  after  reading  them  once  or  twice.  The  other  is 
placed  on  the  middle  of  the  supra-orbital  plate,  and  when  it  is  large  the 
eyeball  is  not  only  rendered  prominent  but  is  depressed,  causing  the 
lower  eyelid  to  assume  the  appearance  of  a  bag  or  fold.  Persons  having 
this  organ  large  have  not  only  an  excellent  memory  for  words,  but  a 
particular  talent  for  the  study  of  languages,  for  criticism,  and  in  gen- 
eral terms  for  all  that  has  reference  to  literature. 

Dr.  Spurzheim,  however,  admits  but  one  organ,  lying  transversely 
on  the  posterior  portion  of  the  supra-orbital  plate,  and  this  view  is  ac- 
cepted by  Combe  and  other  distinguished  phrenological  authorities.1 

In  support  of  his  theory  that  there  is  such  an  organ,  Gall  cites  the 
case  of  a  notary  reported  by  Pinel.2  The  latter,  in  speaking  of  apo- 
plexy, says  this  affection  may  be  limited  in  its  action  to  the  words  which 
arc  used  to  express  ideas.  In  the  case  mentioned,  the  patient  forgot, 
after  an  attack  of  apoplexy,  his  own  name,  that  of  his  wife,  those  of 
his  children  and  friends,  although  there  was  not  the  least  paralysis  of 
his  tongue.  He  no  longer  knew  how  to  read  or  write,  and  yet  his 
memory  as  regarded  other  things  was  unimpaired. 

Dr.  Gall 3  refers  also  to  the  case  of  a  soldier,  sent  to  him  by  Baron 
Larrey,  who  was  affected  in  a  manner  similar  to  that  of  the  notary.  It 
was  not  his  tongue  which  was  involved,  for  he  was  able  to  move  it 
about  in  all  directions,  and  to  pronounce  words,  but  he  had  lost  the 
memory  for  words,  although  he  recollected  other  things  as  well  as  ever. 

I  shall  presently  have  occasion  to  refer  to  a  still  more  interesting 
,  reported  by  Larrey,  and  one  which  appears  to  have  escaped  the 
notice  of  all  writers  on  the  subject  of  aphasia. 

Spurzheim  mentions  the  case  of  one  Lereard,  of  Marseilles,  who, 
o&\ing  received  a  blow  from  a  foil  on  tho  eyebrow  (which  one  is  not 
stated),  lost  the  memory  of  proper  names  entirely.  Ue  sometimes  even 
:   the  names  of  his  intimate,  friends,  and  even  of  his  father. 

1  For  a  full  account  of  the  subject,  the  reader  i*  referred  to  a  "System  of  Plironol. 
Combe,   Boston,  1884,  or  to  "  Phrenology,"  etc.,  by  J.  B.  Spurzheim, 
Boston,  18 

luodico-philosophique,  Bur  ['alienation  mentale."    Second  editii  n. 
18u«j,  p.  (J0.  3  "Physiologic  do  oerveau,"  rol  It.,  p, 


188  DISEASES  OF  THE  BRAIN. 

Gall,  therefore,  located  the  organ  of  language  in  a  limited  part  of 
the  anterior  .lobe  of  each  hemisphere;  but  he  adduced  very  little  evi- 
dence to  support  his  opinion,  and  hence  his  views  did  not  meet  with 
any  thing  like  general  acceptance.  A  number  of  cases,  however,  re- 
ported by  Lallemand,  Rostan,  and  others,  support  it,  while- several  ad- 
duced by  the  same  authors  are  opposed  to  it. 

In  1825  Bouillaud,1  who  had  collected  a  great  number  of  cases  of 
affections  of  the  brain,  was  surprised  to  find  how  frequently  the  loss  of 
speech  coexisted  with  disease  or  injury  of  the  anterior  lobes.  He  also 
confirmed,  what  others  before  him  had  noticed,  that  the  loss  of  the 
power  of  expressing  ideas  in  articulate  language  was  often  the  only  evi- 
dence of  a  brain-affection. 

He  made  one  very  important  step  in  advance,  and  his  views  on  this 
particular  point  are  adopted — and  often  without  credit — by  the  majority 
of  the  present  writers  on  aphasia;  he  divided  the  faculty  of  speech  into 
two  distinct  categories  of  phenomena: 

1.  The  faculty  of  creating  words  as  representatives  of  our  ideas,  and 
of  recollecting  them — internal  speech. 

2.  The  power  of  coordinating  the  movements  necessary  for  the  ar 
ticulation  of  these  words — external  speech. 

This  classification  forms  the  basis  of  the  division  of  aphasia  into  the 
two  varieties,  the  amnesic  and  the  ataxic. 

The  cases  which  Bouillaud  adduced  in  support  of  his  theory  were 
many  of  them  in  patients  who  exhibited  no  other  symptoms  than  the 
loss  of  the  power  of  articulate  language.  They  preserved  their  intelli- 
gence, comprehended  perfectly  questions  put  to  them,  and  knew  the 
value  of  words;  but,  although  there  was  no  paralysis  of  either  the 
tongue  or  the  lips,  they  were  unable  to  utter  a  word.  At  the  post- 
mortem examination,  the  lesion  was  always  found  in  the  anterior  lobes. 
Sixty-four  cases  formed  the  basis  of  his  conclusions.  A  part  was  direct, 
and  went  to  show  that  lesion  of  the  anterior  lobes  was  accompanied 
by  derangement  in  the  faculty  of  speech;  the  other  part  was  indirect, 
and  established  the  fact  that,  when  the  anterior  lobes  were  not  affected, 
the  lesion  being  in  some  other  region  of  the  brain,  the  faculty  of  speech 
remained  intact. 

Cruveilhier  opposed  Bouillaud's  views,  and,  in  a  paper  read  at  the 
Athenee  de  Medecine  in  the  same  year,  brought  forward  seven  cases  of 
persons,  some  of  whom  had  lost  the  faculty  of  speech,  but  who,  on  post- 
mortem examination,  were  found  to  have  no  disease  of  the  anterior 
lobes;  and  others  who  had  spoken,  but  in  whom  there  were  more  or  less 
profound  changes  in  these  parts. 

Subsequently  Andral 3  reported  the  results  of  the  analysis  of  thirty- 

1  "Traite  de  1'encephalite,"  Paris,  1825;  and  also,  "Recherches  cliuiques,  propres  a 
demontrer  que  la  pcrte  de  la  parole  correspond  a  la  lesion  des  lobules  ant6rieurs  du  cer- 
veau,"  Archives  de  mid.,  1825.  2  "  Clinique  medicale,"  tome  ii.,  p.  135. 


APHASIA.  189 

seven  cases  of  lesion  of  one  or  both  anterior  lobes.  Of  these,  speech 
was  abolished  twenty-one  times,  and  preserved  sixteen  times.  Lalle- 
mand '  also  opposed  Bouillaud  with  several  cases;  but  the  latter  rejoined* 
with  a  fresh  array  of  thirteen  cases  in  support  of  his  doctrine,  and  with 
many  arguments  against  the  validity  of  those  brought  against  him. 
Longet '  declares  that  Bouillaud  appears  to  have  refuted  many  of  the 
objections  of  his  adversaries,  and  to  have  demonstrated  that  some  of 
their  cases  were  badly  interpreted.  At  the  same  time,  while  admitting 
that  it  is  possible  that  different  parts  of  the  brain  preside  over  different 
voluntary  movements,  he  affirms  that  there  is  nothing  positively  estab- 
lished as  regards  the  localization  of  the  active  principles  of  these  move- 
ments. 

Subsequently,  in  other  memoirs,  Bouillaud  brought  forward  addi- 
tional cases  in  support  of  his  theory,  making  a  total  of  one  hundred  and 
three,  and  offered  a  prize  of  five  hundred  francs  to  any  one  who  would 
adduce  an  instance  of  profound  lesion  of  the  anterior  lobes  without 
troubles  of  speech.  Many  years  subsequently  Velpeau  announced  that 
he  should  claim  this  prize,  for  that,  in  March,  1843,  he  had  related  the 
case,  and  presented  the  brain,  of  a  wig-maker  who  had  come  under  his 
care  for  prostatic  disease.  This  man  was  in  full  possession  of  his 
reasoning  faculties,  and,  moreover,  was  noted  for  his  unconquerable 
loquacity.  He  died  a  few  days  subsequently,  and  on  post-mortem  ex- 
amination a  scirrhous  tumor  was  found  to  have  entirely  taken  the 
place  of  the  two  anterior  lobes  of  the  brain.  Very  little  faith  seems  to 
have  been  put  by  physiologists  or  pathologists  in  the  history  of  this 
case.  If  it  proves  any  thing,  it  is  that  the  anterior  lobes  are  useless 
appendages  to  the  rest  of  the  cerebral  system. 

But  Bouillaud  was  not  content  with  the  deductions  to  be  drawn 
from  pathology.  In  a  series  of  experiments,  he  endeavored  to  establish 
the  truth  of  his  idea,  and  thus  bring  the  science  of  physiology  to  his 
support.  These  experiments  were  detailed  in  a  paper4  read  before  the 
Academy  of  Sciences,  in  September,  1827,  which  was  subsequently 
(1830)  published  in  the  tenth  volume  of  Magendie's  Journal  de  PhysU 
oloffie,  from  which  I  quote. 

The  experiments  relative  to  the  anterior  lobes  were  made  on  dogs. 
Only  one  was  entirely  successful — the  animals  in  the  others  dying  too 
soon  after  to  admit  of  satisfactory  deductions  being  made.  But  tho 
twentieth  experiment  vras  more  satisfactory. 

On  the  28th  of  June,  182G,  ho  passed  a  gimlet,  through  the  anterior 

1  Op.  -•//.,  lettree  S,  7,  8. 

'  "Exposition  de  oouveaui  fata  \  PappnJ  'li*  l'opinion  qui  localise  dam  lee  lobeo  nn- 
kerleure  'in  cerveao  le  prlncipe  legislateui  de  la  parole."    "Bulletin  de  l'Academie  de 

M6decinc,"  1889,  tOBM  iv.,  p.  282. 

8  "Trail'''  '!>•  la  physiologic,"  tome  ii.,  p.  438. 

•  "Recherohee  expAfimentalee  rax  lei  fonctione  do  oerrean  (lobes  oerebraox)  en  g6no- 

n»l  et  sur  cellos  de  sa  portion  ant6rieure  en  partioulier." 


190  DISEASES  OF  THE  BRAIN. 

part  of  the  brain  of  an  active,  docile,  and  intelligent  dog.  Immediately 
afterward  the  animal  was  convulsed,  and  could  not  rise  from  the  ground. 
Sight  and  hearing  remained.  Symptoms  of  compression  soon  came  on; 
the  result,  probably,  of  the  hasmorrhage.  Eventually,  the  animal  re- 
covered, but  it  was  found  to  have  lost  much  of  its  intelligence  and 
agility.  The  faculty  of  memory  seemed  to  have  been  entirely  abolished, 
and  there  was  a  decided  expression  of  imbecility  in  its  countenance.  It 
could  no  longer  ascend  or  descend  a  staircase;  the  fore-legs  were  lifted 
very  high  in  walking,  and  its  movements  were  all  badly  coordinated. 
'Vhen  struck  or  made  to  walk,  it  uttered  sharp  cries,  but  it  had  lost 
entirely  the  ability  to  bark.  As  Bouillaud  remarks,  "it  no  longer 
barked,  either  to  show  its  affection,  or  to  drive  away  strangers  who 
came  to  the  house."  Once  only,  on  the  18th  of  July,  it  tried  to  bark  at 
a  passer-by,  but  failed  in  the  attempt. 

This  is  the  only  experiment  I  have  been  able  to  find  which  has  any 
bearing  upon  the  question  of  the  localization  of  the  faculty  of  language. 
And  I  do  not  quote  it  as  proving  much  on  the  subject.  The  difficulties 
in  the  way  of  experimentation  are  almost  insuperable,  to  say  nothing  of 
the  fact  that  it  is  doubtful  if  any  of  the  sounds  made  by  animals  can  be 
compared  with  human  speech. 

But  unintentional  experiments  have  been  performed  upon  the 
human  subject,  which  tend  to  show  that,  though  the  faculty  of  lan- 
guage may  be  located  in  one  or  both  anterior  lobes,  cither  may  be 
seriously  injured  without  the  faculty  of  language  suffering  to  any  ap- 
preciable extent.  Two  of  them  have  happened  in  this  country,  and, 
although  referred  to  in  connection  with  aphasia  by  Seguin  and  Harris, 
I  take  satisfaction  in  bringing  them  forward  on  account  of  their  great 
importance  to  the  question  under  consideration. 

The  first  is  related  by  Dr.  Harlow,1  of  Vermont: 

The  subject  was  a  strong,  healthy  man,  twenty-five  years  of  age, 
and  was  engaged  in  ramming  down  a  charge  of  powder  in  a  rock  to  be 
blasted,  when  an  explosion  took  place,  and  the  tamping-iron  was  driven 
clear  through  his  head. 

In  a  few  minutes  he  recovered  his  consciousness,  was  put  into  a  cart 
and  carried  three-quarters  of  a  mile  to  his  residence,  where  he  got  out 
and  walked  into  the  house.  Two  hours  afterward  he  was  seen  by  Dr. 
Harlow.  He  was  then  quite  conscious  and  collected  in  his  mind,  but 
exhausted  by  extensive  hemorrhage  from  the  hole  in  the  top  of  his 
head.  Blood,  pus,  and  particles  of  brain,  continued  to  be  discharged 
for  several  days,  but  by  January  1,  1849,  the  wound  was  quite  closed 
and  his  recovery  complete.  There  was  no  pain  in  the  head,  but  a  queer 
feeling,  which  he  could  not  describe.  As  regarded  his  mind,  he  was 
fitful  and  vacillating,  though  obstinate,  as  he  had  always  been.      He 

1  Boston  Medical  and  Surgical  Journal,  December,  1849,  vol.  xxxix.,  p.  389.     Also, 
"Descriptive  Catalogue  of  the  Warren  Anatomical  Museum,"  Boston,  1870,  p.  145. 


APHASIA.  191 

oecame  very  profane,  never  having  been  so  before  the  accident.  He 
lived  till  May  21,  1SG1,  twelve  and  a  half  years  subsequent  to  the  acci- 
dent, when  he  died,  after  having  had  several  convulsions.  His  cranium 
was  obtained,  and,  with  the  bar,  is  now  preserved  in  the  "Warren  Ana- 
tomical Museum  at  Boston.  Dr.  J.  13.  S.  Jackson l  thus  describes  the 
skull: 

"  The  whole  of  the  small  wing  of  the  sphenoid  bone  upon  the  left 
side  is  gone,  with  a  large  portion  of  the  large  wing,  and  a  large  por- 
tion of  the  orbital  process  of  the  frontal  bone,  leaving  an  opening  in 
the  base  of  the  skull  two  inches  in  length,  one  inch  in  width  poste- 
riorly, and  tapering  gradually  and  irregularly  to  a  point  anteriorly. 
This  opening  extends  from  the  sphenoidal  fissure  to  the  situation  of  the 
frontal  sinus,  and  its  centre  is  an  inch  from  the  median  line.  The  optio 
foramen  and  the  foramen  rotundum  are  intact.  Below  the  base  of  the 
skull  the  whole  posterior  portion  of  the  upper  maxillary  bone  is  gone. 
The  malar  bone  is  uninjured ;  but  it  has  been  very  perceptibly  forced 
outward,  and  the  external  surface  inclines  somewhat  outward  from 
above  downward.  The  lower  jaw  is  also  uninjured.  The  opening  in 
the  base,  above  described,  is  continuous  with  a  line  of  old  and  united 
fracture  that  extends  through  the  supra-orbitary  ridge  in  the  situation 
of  the  foramen,  inclines  toward  and  then  from  the  median  line,  and 
terminates  in  an  extensive  fracture  that  was  caused  by  the  bar  as  it 
came  out  through  the  top  of  the  head.  This  fracture  is  situated  in  the 
left  half  of  the  frontal  bone,  but  inferiorly  it  extends  somewhat  over  the 
median  line.  In  form  it  is  about  quadrilateral;  but  it  measures  two  and 
a  liali'  by  one  and  three-quarter  inches.  Two  large  pieces  of  bone  are 
seen  to  have  been  detached  and  upraised,  the  upper  one  having  been 
separated  at  the  coronal  suture  from  the  parietal  bone,  and  being  so 
closely  united  that  the  fracture  does  not  show  upon  the  outer  sur 
The  lower  piece  shows  the  line  of  fracture  all  around.  Owing  to  the' 
loss  of  bone,  two  openings  arc  left  in  the  skull;  one  that  separates  the 
two  fragments  has  nearly  a  triangular  form,  extends  rather  across  the 
median  line,  and  is  four  inches  in  circumference  ;  the  other,  situated 
between  the  lower  fragment  and  tin-  left  half  of  the  frontal  bone,  is  long 
and  irn  g  ilarly  narrow,  and  is  two  and  five-eighths  inohes  in  cireum- 
ference.  The  edges  of  the  fractured  bones  are  smooth,  and  there  is 
nowhere  any  new  deposit." 

From  this  account  it  will  be  seen  that   the  left  anterior  lobe  of  the 
brain  bu         '         rely  by  this  terrible  injury,  and  yet  it  is  not  stated 

that    tin'    Subject    had    ever    shown    any    difficulties  of   Bpeech.        If    the 

faculty  of  language  resides  in  the  whole  of  the  lobe,  such  an  immunity 
could  scarcely  have  existed.     It  musi  he  noted,  however,  and  tl 
graph  of  the  cranium  establi  ihes  the  fact,  that  the  third  frontal  convo- 
lution and  the  island  of  IJ.il  escaped  all  injury.     Another  interesting 

1  "Descriptive  i'.it  ilogOfl  of  WarreO  Anatomical  Museum,"  /or.  cit. 


192  DISEASES   OF  THE   BRAIN. 

circumstance  is  the  addiction  to  profanity  after  the  accident.  A  like 
phenomenon  has  been  noticed  in  cases  of  aphasia. 

The  second  instance  is  almost  as  extraordinary.  I  quote  the  history 
of  the  case,  952,  from  Dr.  Jackson: ' 

"  Cast  of  tlie  head  of  a  man  who  was  transfixed  through  the  head  by 
an  iron  gas-pipe,  and  who,  to  a  very  considerable  extent,  recovered  from 
the  accident. 

"The  patient,  a  healthy  and  intelligent  man,  about  twenty-seven 
years  of  age,  was  blasting  coal  when  the  charge  exploded  unexpectedly, 
and  the  pipe  was  driven  through  his  head,  entering  at  the  junction  of 
the  middle  and  outer  thirds  of  the  right  supra-orbitary  ridge,  and  emerg- 
ing near  the  junction  of  the  left  parietal,  occipital,  and  temporal  bones. 
One  of  his  fellow-miners  saw  him  upon  his  hands  and  knees,  and  strug- 
gling as  if  to  rise  ;  and,  going  to  his  assistance,  he  placed  his  knee  up- 
on his  chest,  supported  his  head  with  one  hand  and  with  the  other  with- 
drew the  pipe.  This  last  projected  about  equally  from  the  front  and 
back  of  the  head,  and  much  force  was  required  for  its  withdrawal." 

Brain  escaped  from  the  anterior  opening,  and  coma  and  collapse 
supervened.  "  In  seven  weeks  he  sat  up,  and  in  one  more  walked  about. 
The  right  hand  he  used  somewhat,  but  less  well  than  the  left.  For 
about  ten  months  after  the  accident  his  memory  for  some  things  was 
nearly  lost,  but  during  the  next  two  months  there  was  a  considerable 
improvement." 

The  accident  happened  on  May  14,  1867,  and  in  June,  1868,  the 
patient,  with  the  gas-pipe,  was  exhibited  to  the  Massachusetts  Medical 
Society.  "  The  man  appeared  to  be  in  a  good  state  of  general  health ; 
and,  though  his  mental  powers  were  considerably  impaired,  there  was 
nothing  unusual  in  his  expression,  nor  would  there  be  noticed,  in  a  few 
minutes'  conversation  with  him,  any  marked  deficiency  of  intellect." 

It  is  very  evident  that  in  this  case  the  right  anterior  lobe  was 
seriously  injured — the  left  escaping — and  yet  there  does  not  appear  to 
have  been  any  aberration  of  speech.  It  is  to  be  regretted,  however, 
that  the  history  is  not  more  specific  as  to  the  things  in  regard  to  which 
the  memory  was  deficient. 

There  are  other  cases  which  militate  against  Bouillaud's  doctrine. 
Thus,  M.  Peter 2  states  that  a  drunken  cavalry -soldier  fell  from  his  horse 
on  the  back  of  his  head,  and  fractured  his  skull.  Stupor  set  in  at  once, 
followed  by  the  most  violent  delirium.  The  man  kept  constantly  shout- 
ing the  worst  possible  oaths,  and  held  connected  conversation  with  im- 
aginary persons.  He  died  at  the  end  of  thirty -six  hours,  without  hav- 
ing recovered  his  reason.  On  dissection,  a  fracture  of  the  roof  and  base 
of  the  skull  was  discovered  in  all  its  length.     The  posterior  lobes  of  the 

1  Op.  cit.,  p.  149. 

*  Quoted  by  Trousseau,  "  Lectures  on  Clinical  Medicine."  Translated  by  Bazire,  vol. 
L,  p.  256. 


APHASIA.  193 

brain  were  found,  on  post-mortem  examination,  to  have  sustained  no 
injury,  but  both  anterior  lobes  were  in  a  pulpy  condition,  through  a 
most  violent  contusion,  caused  by  their  being  knocked  against  the  an- 
terior wall  of  the  cranium.  The  whole  thickness  of  the  lobes  was  dis- 
organized. As  Trousseau  remarks,  this  case  shows  that  the  two  frontal 
lobes  may  be  destroyed  in  their  anterior  portion  without  causing  a  loss 
of  the  faculty  of  speech.  Trousseau  also  cites  the  case  of  two  officers, 
who,  after  a  quarrel,  fought  a  duel.  One  of  them  fired  first,  and  the 
ball  entered  his  adversary's  head  at  one  temple,  passed  through  the 
brain,  and  then  raised  the  temporal  bone  on  the  opposite  side.  The 
ball  was  extracted,  and  the  patient  immediately  made  a  sign  with  his 
hands,  and  expressed  his  thanks  in  a  very  low  voice.  He  recovered,  for 
the  time  being,  and,  during  five  months  thereafter,  could  speak  perfect- 
ly well,  and  was  remarkable  for  the  wit  and  fluency  of  his  conversation 
and  writing.  He  subsequently  died  of  softening;  and  it  was  found,  on 
post-mortem  examination,  that  the  ball  had  passed  through  the  two 
frontal  lobes  in  their  middle  portion.  A  still  more  striking  case  is  re- 
ferred to  by  Dr.  Bazire,  in  a  note  to  Trousseau's  lecture  on  aphasia,  in 
the  work  cited.  It  was  reported  in  1843  by  M.  Aug.  Berard,  to  the 
Anatomical  Society  of  Paris.  The  patient,  a  miner,  was  knocked  down 
and  severely  injured  by  an  explosion  in  a  mine.  He  did  not  lose  con- 
sciousness, but  managed  to  creep  out  of  his  hole  and  to  call  to  his  help 
some  men  who  were  working  a  short  distance  off.  He  begged  them  to 
fetch  a  cart  and  to  take  him  to  M.  Berard's  house.  He  was  there  ex- 
amined. The  whole  frontal  region  was  laid  open,  the  integuments  hung 
in  shreds,  the  bones  were  splintered  and  in  detached  fragments,  and  the 
lna in  was  exposed.  Both  anterior  cerebral  lobes  were  completely  de- 
stroyed, and  in  their  stead  was  a  mixture  of  blood,  of  bony  splinters, 
and  brain-substance.  In  spite  of  this  frightful  injury,  the  man  could 
relate  in  all  its  details  how  the  accident  had  occurred.  He  died  the 
next  day. 

Whether  or  not  we  accept  this  case  in  all  the  import  claimed  for  it, 
then;  can  be  no  doubt  that  Bouillaud  is  wrong  in  claiming  that  injury 
of  the  anterior  lobes  is  necessarily  followed  by  some  derangement  in  the 
faculty  of  speech.  It  is  only  fair, however,  to  state  that  latterly  he  has 
admitted  thai  the  organ  of  language  may  occupy  the  posterior  pari  of 
'•ither  lobe. 

Dr.  M.  Dax,  in  1836,  read  a  paper  before  the  medical  oongress  which 
met  that  year  at  Biontpellier,  in  which  he  came  to  the:  conclusion  that 
the  faculty  of  language  "  was  Beated,  not  as  Gall  and  Bouillaud  had 
contended,  in  both  anterior  lobes  of  the  brain,  but  that  it  ocoupied  only 
the  left  anterior  lobe."  lb'  based  this  opinion  on  one  hundred  and 
forty  cases  of  aphasia  .attended  with  paralysis,  and  in  which  the  loss  of 

power  was  on  t  he  right  side;    showing,  t  herefore,  that    the    lesion    which 
produced  the  aberration  of  Bpeech  also  caused  the  hemiplegia,  and  that 
1  1 


194  DISEASES   OF  THE   BRAIN. 

this  lesion  must  have  been  on  the  left  side.  This  paper  at  the  time  at- 
tracted very  little  attention,  and  was  forgotten  till  the  year  18C1  wit- 
nessed the  reopening  of  the  discussion.1 

It  would  be  very  easy  to  quote  a  large  number  of  cases  confirmatory 
of  Dr.  Dax's  doctrine,  but  a  few  will  suffice  to  show  the  general  bearing 
of  a  great  many  others.  The  following  case  seems  to  have  escaped 
notice.  It  is  not  the  one  referred  to  by  Gall  as  being  sent  to  him  b) 
Larrey.  In  that  case  the  left  anterior  lobe  was  injured  and  there  wat 
aphasia,  but  the  lesion  was  caused  by  a  sword. 

Baron  Larrey 2  presented  to  the  Academy  the  cranium  of  a  subject 
with  the  following  history: 

Toward  the  end  of  the  year  1815  an  officer  of  dragoons  came  to  the 
hospital  with  a  wound  from  a  ball  which  he  had  received  at  Waterloo. 
The  missile  had  entered  the  left  side  of  the  cranium  at  a  point  about 
six  or  eight  millimetres  from  the  eyebrow  and  near  the  temporal  ridge. 
At  first  he  had  suffered  loss  of  consciousness  and  profuse  hasmorrhage, 
but  had  recovered,  with  but  slight  loss  of  motor  power.  So  far  as  his 
mind  was  concerned,  there  was  no  derangement  except  as  regarded  the 
faculty  of  speech;  he  had  lost  the  memory  of  substantives.  For  this 
reason  he  was  unable  to  drill  his  company,  and,  though  able  to  distin- 
guish his  men  by  their  size,  their  form,  their  complexion,  or  their  voice, 
he  could  not  call  them  by  name.  He  refused  to  allow  the  operation  of 
trephining  to  be  performed,  and  in  1827  died  of  phthisis. 

A  post-mortem  examination  was  made.  The  ball  was  found  em- 
bedded in  the  thickness  of  the  bone,  having  elevated  and  fractured  the 
internal  table.  The  dura  mater  was  strongly  adherent  to  the  whole  of 
the  left  anterior  cranial  fossa;  it  was  also  thicker  and  denser  than  in  the 
natural  state.  A  spheroidal  excavation,  five  centimetres  in  its  horizontal 
and  seven  or  eight  in  its  vertical  diameter,  was  discovered  at  the  summit 
and  on  the  temporal  side  of  the  left  anterior  lobe  of  the  brain. 

Mr.  Thomas  Hood  3  reported  the  history  of  a  patient,  a  sober,  intel- 
ligent man,  sixty  years  of  age,  who,  on  the  evening  of  September  2, 
1822,  suddenly  began  to  speak  incoherently,  and  became  quite  unintelli- 
gible to  those  around  him.  It  was  discovered  that  he  had  forgotten  the 
name  of  every  object  in  Nature.  His  recollection  of  things  seemed  to 
be  unimpaired,  but  the  names  by  which  men  and  things  were  known 
were  entirely  obliterated  from  his  mind,  or  rather  he  had  lost  the  faculty 
by  which  they  were  called  up  at  the  control  of  the  will.  He  was  by  no 
means  inattentive,  however,  to  what  was  going  on,  and  he  recognized 

1  Dr.  Marc  Dax's  memoir  was  republished  in  the  Gazette  hebdomadaire,  No.  17,  April, 
1865. 

2  "  Blcssure  du  cerveau  avec  perte  de  memoire  des  noms  substantives,"  Journal  de 
physiologic  de  Magendie,  tome  viii.,  1828,  p.  1. 

3  "  Phrenological  Transactions."  Quoted  by  George  Combe  in  his  "  System  of  Phre- 
nology," Boston,  1834,  p.  429. 


APHASIA.  19.') 

friends  and  acquaintances  perhaps  as  quickly  as  on  any  former  occasion; 
but  their  names,  or  even  his  own  or  his  wife's  name,  or  the  names  of  any 
of  his  domestics,  appeared  to  have  no  place  in  his  recollection. 

"  On  the  morning  of  the  4th  of  September,"  says  Mr.  Hood,  "  much 
against  the  wishes  of  his  family,  he  put  on  his  clothes  and  went  out  to 
the  workshop,  and  when  I  made  my  visit  he  gave  me  to  understand,  by 
a  variety  of  signs,  that  he  was  perfectly  well  in  every  respect,  with  the 
exception  of  some  slight  sensations  referable  to  the  eyes  and  eyebrows. 
I  prevailed  on  him  with  some  difficulty  to  submit  to  the  reapplication  of 
leeches,  and  to  allow  a  blister  to  be  placed  over  the  left  temple.  He 
was  now  so  well  in  bodily  health  that  he  would  not  be  confined  to  the 
house,  and  his  judgment,  in  so  far  as  I  could  form  an  estimate  of  it,  was 
unimpaired,  but  his  memory  of  words  was  so  much  a  blank,  that  the 
monosyllables  of  affirmation  and  negation  seemed  to  be  the  only  two 
words  in  the  language  the  use  and  significance  of  which  he  never  en- 
tirely forgot.  He  comprehended  distinctly  every  word  which  was  spoken 
or  addressed  to  him;  and,  though  he  had  ideas  adequate  to  form  a  full 
reply,  the  words  by  which  these  ideas  are  expressed  seemed  to  have 
been  entirely  obliterated  from  his  mind.  By  way  of  experiment  I  would 
sometimes  mention  to  him  the  name  of  a  person  or  thing,  his  own  name 
for  example,  or  the  name  of  some  one  of  his  domestics,  when  he  would 
repeat  it  after  me  distinctly  once  or  twice;  but  generally  before  he  could 
do  so  a  third  time  the  word  was  gone  from  him  as  completely  as  if  ho 
had  never  heard  it  pronounced.  When  any  person  read  to  him  from  a 
book,  he  had  no  difficulty  in  perceiving  the  meaning  of  the  passage,  but 
he  could  not  himself  then  read,  and  the  reason  seemed  to  be  that  he  had 
forgotten  the  elements  of  written  language,  viz.,  the  names  of  the  let- 
ters of  the  alphabet.  In  the  course  of  a  short  time  he  became  very  ex- 
pert in  the  use  of  signs,  and  his  convalescence  was  marked  by  his  im- 
perceptibly acquiring  some  general  terms  which  were  with  him,  at  first, 
of  very  extensive  and  varied  application.  In  the  progress  of  his  recov- 
ery, lime  and  space  came  both  under  the  general  application  of  time. 
All  future  events  and  objects  before  him  were,  as  he  expressed  it,  '  m  Xt 
time/1  but  past  events  and  objects  behind  him  were  designated  lkut 
time.1  One  day,  being  asked  his  age,  he  made  me  to  understand  thai 
he  could  not  t el!;  but,  pointing  to  his  wife,  uttered  the  words,  tmany 
times1  repeatedly,  as  much  as  to  say  that  he  had  often  told  her  his  age. 

When  Bhe  answered  si\tv,  he  answered  in  the  affirmative." 

( >n  the  10th  of  January  he  suddenly  became  paralytio  on  the  left 
side  [this  is  evidently  a  typographical  error  Cor  right  side].  On  the  17th 
of  An.";  t  he  had  an  attack  of  apoplexy,  and  on  the  ',11st  he  expired. 
In  the  Phrenological  Journal,  vol,  iii..  p,  38,  Mr.  1 1 . » < »<  1  has  reported 
the  dj  section  of  his  brain:  "  In  the  left  hemisphere,  lesion  of  the  parts 
was  found,  which  terminated  a1  half  an  inch  from  the  surface  of  the 
brain,  where  it  rests  on  the  middle  of  the  supra-orbital  plate."     Two 


196  DISEASES   OF   TEE   BRAIN. 

small  depressions  or  cysts  were  found  in  the  substance  of  the  brain, 
"  and  the  cavity  considered  as  a  whole  expanded  from  the  anterior  part 
of  the  brain  till  it  opened  into  the  ventricle  in  the  form  of  a  trumpet. 
The  right  hemisphere  did  not  present  any  remarkable  appearance." 

Dr.  Thomas  Hun,1  of  Albany,  in  detailing  a  case  of  amnesia  in 
which  there  were  no  symptoms  of  paralysis,  and  in  which  there  was 
no  post-mortem  examination,  cites  the  case  of  a  lady  who  died  of  cancer 
of  the  brain,  occupying,  at  the  time  of  her  death,  the  greater  portion 
of  the  left  anterior  lobe.  In  the  early  stages  of  her  disease  she  was 
often  unable  to  call  the  most  familiar  objects  by  name,  and  had  to  ex- 
press herself  by  signs  or  by  pointing  at  the  object.  When  the  word 
she  wanted  was  pronounced  before  her,  she  recognized  it,  and  was  able 
to  repeat  it. 

Other  cases,  and  especially  several  which  have  occurred  in  my  own 
experience,  are  reserved  for  future  consideration. 

Up  to  this  period  we  have  the  organ  of  articulate  language  limited 
to  the  left  anterior  lobe  of  the  brain,  but  in  1861  its  location  was  still 
further  restricted.  In  that  year  M.  Gratiolet,  in  discussing  before  the 
Anthropological  Society  of  Paris  a  question  relative  to  the  comparative 
development  of  the  brain  and  mind  among  different  races,  brought  up 
the  subject  of  cerebral  localization,  to  which  he  announced  himself  as 
being  strongly  opposed.  M.  Auburtin,  on  the  contrary,  contended  that 
the  localization  of  the  faculty  of  speech  at  least  was  definitely  estab- 
lished, through  the  researches  of  Bouillaud,  in  the  anterior  lobes.  In 
support  of  this  view,  he  adduced  cases  which  had  already  been  brough 
forward,  and  cited  others  in  addition,  which  went  to  show  that  loss  of 
speech  was  the  consequence  of  traumatic  lesion  of  these  parts  of  the 
brain.  His  adversaries  cited  other  cases  in  which  persons  had  preserved 
the  faculty  of  language  notwithstanding  extensive  lesions  of  the  an- 
terior lobes.  M.  Auburtin  responded  that,  if  such  profound  and  exten- 
sive injuries  had  not  interfered  with  speech,  it  was  because  that  part  of 
the  lobes  in  which  the  organ  is  situated  was  not  involved.  And  he  then 
cited  the  case  of  a  patient  in  the  Hospital  for  Incurables,  who  for  many 
years  had  been  deprived  of  the  power  of  speech,  and  he  declared  that 
he  would  renounce  the  doctrine  of  Bouillaud  if  the  autopsy  of  this 
patient  did  not  reveal  disease  of  the  anterior  lobes.  The  patient  in 
question  was  under  the  charge  of  M.  Broca,  and  the  latter,  a  decided 
opponent,  accepted  the  challenge  of  M.  Auburtin,  and  declared  that, 
when  the  man  died,  the  examination  should  be  made. 

Some  time  afterward  the  patient  died,  the  post-mortem  examination 
vvas  made,  and  the  lesion  was  found  to  occupy  the  left  anterior  lobe.2 

From  this  time  forward,  M.  Broca,  who  had  been  a  most  determined 

1  American  Journal  of  Insanity,  vol.  vii.,  1850-'61,  p.  359. 

2  See  "  Etude  sur  la  localisation  dc  la  faculte  du  langage  articuleV'  These  de  Pari* 
ao  M   Carrier,  1867. 


APHASIA.  197 

opponent  of  Bouillaud's  views  of  localization,  became  converted,  anti 
carried  them  to  a  still  more  extreme  point  than  even  M.  Marc  Dax  had 
done.  Taking,  as  his  principal  case,  the  one  to  which  M.  Auburtin  had 
pinned  his  faith,  he  read,  in  1861,  before  the  Anatomical  Society  of 
Paris,  a  memoir,1  in  which  he  discusses  the  question  of  the  location  of 
the  faculty  in  question  with  all  his  perspicuity  and  directness.  As  the 
two  cases  cited  by  him  are  of  historical  interest,  I  give  the  chief  details 
of  them: 

A  man  named  Le  Borgne,  who  had  been  an  inmate  of  another  de- 
partment of  Bicetre  for  over  twenty  years,  was  transferred  to  one  of 
the  wards  under  M.  Broca's  care,  to  be  treated  for  a  severe  attack  of 
phlegmonous  erysipelas.  The  man  was  a  confirmed  epileptic,  and  had 
not  spoken,  since  his  entrance  into  the  hospital,  more  than  a  few  words, 
which  he  employed  for  the  expression  of  all  his  ideas.  It  is  stated  that 
in  other  respects  his  intelligence  was  good.  Le  Borgne  was  known  in 
the  hospital  by  the  name  of  "Tan,"  a  word  which  he  habitually  used, 
and  which,  with  the  oath,  "  Sacrb  nam  cle  Dieu"  constituted  his  entire 
vocabulary.  "  Tan,"  owing  to  the  constancy  with  which  he  used  it,  was 
the  name  by  which  he  was  known  in  the  hospital;  and,  when  he  could 
not  make  himself  understood  by  his  signs,  he  employed  the  oath,  and 
gave  other  manifestations  of  anger. 

For  several  years  he  had  remained  in  the  hospital  with  no  other 
lesion  than  that  of  speech,  with  an  occasional  epileptic  paroxysm;  but, 
after  a  few  years,  his  right  arm  became  paralyzed,  and  four  years  sub- 
sequently the  leg  of  the  same  side  was  involved;  his  sight  was  likewise 
enfeebled,  and  for  the  past  seven  years  he  had  been  entirely  confined 
to  his  bed. 

Notwithstanding  the  fact  that  he  was  almost  in  a  dying  condition 
when  M.  Broca  first  saw  him,  some  important  points  in  his  cerebral 
difficulty  were  noted.  To  any  question  put  to  him,  he  replied,  as  usual, 
"  Tan"  but  at  the  same  time  endeavored  to  make  himself  understood 
by  signs.  Thus  he  raised  six  fingers  to  indicate  that  six  days  had 
elapsed  since  the  inception  of  his  erysipelas,  and  by  opening  and  shut- 
ting his  hand  four  times  and  then  raising  one  finger  signified  that  he 
had  1 ri  twenty-one  years  in  Bicetre. 

Sensibility  was  lessened  <>n  (lie  affected  side;  there  was  no  deviation 
if  the  tongue,  which  could  be  moved  freely  in  all  directions,  and  no 
paralysis  of  the  face  beyond  a  slight  weakness  shown  by  the  swelling  of 
the  left  side  when  be  breathed;  there  was  a  little  difficulty  of  swallow- 
ing,  from  the  Fact  thai  the  muscles  of  the  pharynx  were  gradually  be- 
coming implicated.     After  a  few  days  the  man  died. 

As  I  have  said,  the  autopsy  showed  thai  the  lesion  was  situated  in 
the  left  anterior  Lobe.     .More  exactly,  however,  it   should  now  be  stated 

1  "Sur  le  siege  de  la  foculte'  de  langage  artlcule'  arec  detu  obterrationa  d'nphemle." 
Bulletin  de  l*i  todM  cmatomiqvt,  ton  e  iv.,  1861. 


198  DISEASES  OF  THE   BRAIN. 

that  it  involved  the  inferior  marginal  convolution  of  the  tempore- 
sphenoidal  lobe,  the  convolutions  of  the  island  of  Reil,  and  in  the  fron- 
tal lobe,  the  frontal  transverse  convolution,  and  the  posterior  half  of 
the  second  and  third  frontal  convolutions.  The  left  corpus  striatum 
was  also  affected.  According  to  Broca,  the  disease  had  in  all  probabil- 
ity begun  in  the  third  frontal  convolution,  and  had  gradually  extended  t 
to  the  other  parts;  the  paralysis  marking  the  implication  of  the  island 
of  Reil  and  the  corpus  striatum. 

The  other  case  was  that  of  a  man  named  Le  Long,  aged  eighty-four 
years,  who  had  entered  the  hospital  for  a  fracture  of  the  neck  of  the 
femur.  Eighteen  months  before,  he  had  been  treated  in  the  medical 
service  for  a  temporary  apoplexy,  which  had  deprived  him  of  the  faculty 
of  speech,  but  had  caused  no  paralysis.  Le  Long,  whose  intelligence, 
facial  expression,  and  ability  to  gesticulate,  were  very  striking,  made 
himself  perfectly  well  understood,  although  able  to  pronounce  indistinct- 
ly a  very  few  words,  but  which  were  nevertheless  properly  applied. 
These  words  were  " oui"  " non,  toujo:trs,  tois "  for  trots,  and  Lelo  for 
Le  Long.  Thus  when  asked,  "  Can  you  write  ?  "  he  answered,  "  Oui." 
"  Have  you  any  children  ?  "  "  Oui."  "  How  many  ?  "  "  Tois,"  but  at  the 
same  time,  as  if  aware  that  he  was  not  answering  correctly,  he  raised 
four  fingers.  "  How  many  boys  ?  "  "Tois,"  raising  two  fingers.  "  How 
many  girls  ?"  "  Tois,"  holding  up  two  fingers.  "  What  time  is  it  by  this 
watch '? "  "  Tois,"  at  the  same  time  raising  ten  fingers  to  signify  that 
it  was  ten  o'clock.  "  How  old  are  you  ?  "  To  this  question  he  replied 
by  two  gestures  ;  the  one  consisting  of  raising  eight  fingers,  the  other 
of  four  fingers,  by  which  he  meant  that  he  was  eighty-four  years  old. 

Aside  from  this  application  of  the  word  tois  to  all  numbers,  his 
answers  were  perfectly  correct.  The  tongue  was  neither  paralyzed  nor 
thickened;  on  one  side  the  larynx  was  mobile,  and  his  limbs  possessed 
their  normal  power  for  his  age.  It  was  therefore  a  case  of  pure  aphasia 
or,  as  Broca  then  designated  the  affection,  aphemia. 

Twelve  days  after  the  accident,  the  patient  died.  The  post-mortem 
examination  revealed  the  existence  of  lesions,  almost  identical  in  situa- 
tion with  those  of  the  former  case.  The  posterior  part  of  the  third  left 
frontal  convolution,  and  the  contiguous  part  of  the  second,  had  been 
absorbed  and  replaced  by  a  serous  fluid.  Two  cases  can  scarcely  decide 
any  point  in  pathology;  but,  without  venturing  to  assert  positively  that 
the  organ  of  language  resides  exclusively  in  the  posterior  part  of  the 
third  frontal  convolution,  M.  Broca  expressed  the  opinion  that  the  in- 
tegrity of  this  convolution,  and  perhaps  of  the  second,  is  indispensable 
v,o  the  normal  operation  of  the  function  of  speech. 

Many  cases  were  adduced  by  Charcot,1  by  Falret,5  by  Perroud     of 

1  Gazette  hebdomadaire,  1863,  pp.  4Y3,  525. 

8  Archives  de  medecine,  tome  iv.,  Mars  et  Mai,  1864. 

s  Journal  de  medecine  de  Lyon,  Janvier  et  Fevrier.  18C4. 


APHASIA.  199 

Lyons,  by  Trousseau,1  and  others,  in  support  of  the  localization  of  the 
faculty  of  articulate  language  in  the  left  side  of  the  brain.  Most  of 
these  cases  were  accompanied  by  right  hemiplegia,  and,  in  several,  post- 
mortem examinations  showed  the  lesion  to  exist  in  the  parts  designated 
by  Broca. 

In  the  early  part  of  1833,  M.  G.  Dax,  son  of  the  M.  Dax  who  had 
placed  the  organ  of  language  in  the  left  hemisphere,  presented,  through 
M.  Lelut,  a  memoir  to  the  Academy,  in  which  he  claimed  with  his  father 
that  aphasia  was  always  the  result  of  lesion  of  the  left  hemisphere,  but 
he  assigned  a  still  more  restricted  position,  by  limiting  it  to  the  anterior 
and  exterior  part  of  the  middle  lobe.  He  cited  forty  cases  of  loss  of 
the  power  of  speech,  coincident  with  lesion  of  the  left  hemisphere. 

Now,  besides  these  direct  cases,  there  are  others  which  bear  with 
almost  as  much  effect  on  the  affirmative  of  the  doctrine  in  question, 
Thus  M.  Fernet,  in  18G3,  presented  a  case  to  the  Soci6te*  de  Biologie,  in 
which  there  was  left  hemiplegia,  but  no  aphasia.  After  death,  soften- 
ing of  the  right  hemisphere,  from  thrombosis  of  the  right  middle  cere- 
bral artery,  was  found  to  exist.  M.  Parrot a  adduced  another  case  in 
which  there  was  complete  atrophy  of  the  island  of  Reil,  and  of  the  third 
convolution  of  the  right  side,  but  in  which  there  was  no  trouble  of 
speech.  These  cases  go  to  show  that  the  organ  of  articulate  language 
is  not  situated  in  the  right  hemisphere. 

M.  Lesur 3  has  reported  a  case  which  is  of  very  great  interest.  A 
child  was  kicked  on  the  head  by  a  horse,  and  a  fracture  of  the  frontal 
bone  was  thus  produced.  The  operation  of  trephining  was  performed 
at  a  point  about  an  inch  and  a  quarter  above  the  left  eye.  After  the 
operation  and  during  the  progress  of  the  case,  it  was  observed  that, 
whenever  pressure  was  made  upon  the  brain  through  the  hole  in  the 
cranium,  the  child  lost  the  power  of  speech,  and  that  when  this  pressure 
was  removed  she  regained  it.  A  similar  case  occurred  seven]  years  ago 
in  my  own  practice. 

Among  British  writers,  Dr.  Hughlings  Jackson  nas  given  the  histo- 
ries of  thirty-four  cases  of  loss  of  speech  coinciding  with  right  hemiph  - 
gia.  lie  is  entitled  to  the  credit  of  making  a  beautiful  application  of 
anatomy  and  physiology  to  the  pathology  of  the  subject  under  considera- 
tion. The  part  of  the  brain  designated  by  Broca  as  the  seat  of  the 
organ  of  articulate  language  is  nourished  by  the  left  middle  cerebr.il 
artery.  An  obstruction  of  this  artery  would  of  course  interfere  with 
the  perfect  action  of  that  region,  and  thus  aberrations  of  Bpeeoh  would 
be  produced.  But  the  same  artery  also  supplies  blood  to  the  corpus 
striatum  of  the  same  side.  Hence  the  frequency  with  which  aphasia  is 
associated  with  right  hemiplegia.  The  cause  of  the  obstruction  is  gener- 
ally, according  to  Dr.  Jackson,  embolism,  for  in  twenty  of  his  oases  the 

!  Cliniqut  midieaU.  »  Ghuette  Ktbdomadaire,  I8i 

8  Gautk  det  h  '/>itaux.  *  "London  Hospital  Ropor'9,"  vol.  L 


200  DISEASES   O.F   THE   BRAIN. 

heart  was  more  or  less  affected,  and  in  thirteen  of  them  there  was  valvu 
lar  disease. 

Among  other  British  writers,  some  of  whom  will  be  more  fully  re- 
ferred to  hereafter,  must  be  mentioned,  Dr.  Sanders,1  Dr.  Moxon,2  Dr. 
Ogle,3  Dr.  Bateman,4  and  Dr.  Bastian.6 

The  matter  does  not  appear  to  have  attracted  much  attention  from 
German  physiologists  and  pathologists,  since  the  discussion  in  the 
French  Academy  in  18G1.  Previous  to  that  period  several  excellent 
memoirs  upon  the  physiology  of  speech  were  published  by  Germans, 
among  which  that  of  Dr.  Bergman 6  is  preeminent.  A  memoir  by  Nasse 7 
is  also  interesting. 

In  1865  Von  Benedict  and  Braunwart  8  published  a  very  thorough 
paper  on  the  subject,  and  other  observers  have  reported  cases. 

In  this  country  there  have  been  several  very  excellent  memoirs  upon 
aphasia,  and,  as  we  have  already  seen,  the  subject  early  attracted  atten- 
tion, and  the  fact  that  such  a  condition  could  exist  without  other  mani- 
fest symptoms  was  fully  recognized.  Thus  Prof.  A.  Flint 9  detailed  the 
histories  of  six  cases,  in  one  of  which  post-mortem  examination  showed 
extensive  disease  of  the  left  anterior  lobe,  and  in  four,  in  which  the 
situation  of  the  hemiplegia  was  noted,  the  right  was  the  affected  side. 

Dr.  H.  B.  Wilbur,10  in  a  memoir  on  aphasia,  treats  of  the  aberrations 
of  the  faculty  of  language  as  they  existed  in  certain  idiots  under  his 
observation.  His  cases,  though  interesting,  are  scarcely  in  point,  as  the 
difficulties  of  speech  were  clearly  the  result  of  mental  deficiencies. 

A  very  important  memoir  is  that  of  Dr.  E.  C.  Seguin,11  in  which  a 
very  excellent  history  of  the  subject  is  given,  with  the  citation  of  forty- 
eight  cases  from  the  records  of  the  New  York  Hospital,  in  which  there 
were  difficulties  of  speech  coexisting  with  hemiplegia,  and  two  in  which 
there  was  no  hemiplegia.  In  several  of  these  cases,  hoAvever,  as  Dr. 
Seguin  states,  the  loss  of  the  faculty  of  speech  was  due  to  paralysis  of 
the  tongue  and  other  muscles  concerned  in  articulation. 

Another  excellent  paper  is  by  Dr.  T.  W.  Fisher,12  of  Boston.  Dr. 
Fisher  has  studied  the  subject  very  philosophically,  and  records  thirty- 

1  Edinburgh  Medical  Journal,  August,  1866. 
a  British  and  Foreign  Medico- Chirurgical  Review,  April,  1866. 
3  "St.  George's  Hospital  Reports,"  vol.  ii.,  1867. 
*  Journal  of  Menial  Science,  January,  1868,  and  subsequent  numbers. 
5  British  and  Foreign  Medico- Chirurgical  Review,  January  and  April,  1869. 
6"Einige  Bemerkungen  iiber  Stiirungen  des  Gedachtnias  uud  der  Sprache.     Alio* 
nc'.ne  Zeitschrift  fur  Psychiatrie,  1849,  s.  057. 

I  Allgemeine  Zeitschrift  u.  s.  w.,  1853,  s.  523. 

8  Canstatt's  "  Jahresbericht,"  1865,  s.  31. 

9  Medical  Record  (New  York),  March  1,  1866. 

10  American  Journal  of  Insanity,  July,  1867. 

II  Quarterly  Journal  of  Psychological  Medicine,  etc.,  January,  1868. 

12  Boston  Medical  and  Surgical  Journal,  September  1,  1870,  and  subsequent  numbers. 


APHASIA.  201 

eight  cases  in  which  post-mortem  examinations  were  made  with  defi- 
nite results.  Cases  have  also  been  published  by  Bartholow1  and 
others. 

With  this  outline  statement  of  the  history  of  the  subject  of 
aphasia,  we  are  in  a  position  to  inquire  more  fully  into  the  evi- 
dence which  locates  the  organ  of  language  in  a  particular  region  of 
the  brain. 

Aphasia,  as  it  is  now  understood,  comprises  several  distinct  vari- 
eties. At  the  time  Wernicke's8  scientific  work  appeared,  aphasia 
was  classified  as  either  ataxic  or  as  amnesic.  But  Wernicke's  care- 
ful study  of  the  subject  led  him  to  discard  these  terms  and  to  sub- 
stitute in  their  place  the  terms  motor  aphasia  and  sensory  aphasia. 
Ktissmaul3  shortly  afterward  made  a  further  advance  by  separat- 
ing sensory  aphasia  into  its  two  component  parts,  word-deafness  and 
word-blindness.  In  addition  to  motor  aphasia,  word-deafness,  and 
word-blindness,  we  also  recognize  agraphia,  paraphasia,  amnesia,  and 
apraxia. 

Each  one  of  these  forms  will  now  be  considered  in  detail. 

Motor  aphasia  consists  of  the  loss  of  the  memory  of  how  to  make 
the  muscular  movements  of  the  lips  and  tongue  necessary  for  the 
articulation  of  words. 

When  this  form  of  aphasia  exists  alone,  the  power  of  voluntary 
speech  is  abolished,  and  also  the  power  of  repeating  words  that  are 
heard.  There  is  no  difficulty  in  comprehending  written  or  printed 
letters  or  words,  or  of  understanding  words  that  are  heard.  The 
individual  has  simply  forgotten  how  to  place  his  tongue  and  lips  in 
the  proper  positions  for  producing  articulate  speech,  but  can  readily 
express  his  ideas  by  signs,  by  selecting  the  proper  letters  from  an 
alphabet  to  spell  out  words,  and  also  by  writing,  if  the  lesion  is  not 
cortical,  and  if  the  muscles  of  the  arm  are  not  too  paretic 

Word-deafness  consists  of  the  loss  of  the  memory  of  the  sound 
of  words.  To  a  person  affected  with  word-deafness  his  own  lan- 
guage sounds  to  him  like  a  tongue  with  which  he  is  totally  un- 
familiar. He  bears,  bul  does  not  comprehend  the  meaning  of  the 
sounds. 

Word-deafness  musl  not  be  confounded  with  word-amnesia.  In 
the  latter  case  the  word  is  forgotten,  bul  is  immediately  recognized  as 
Boon  as  it  is  heard,  while  in  word-deafnese  it  is  qoI  understood  at 
all.     Word-deafness  and  auditory  amnesia    usually  accompany   each 

other. 

Word-blindness  is  the  loss  of  the  memory  of  the  appearan 

words.     As  the  form  of  the  letters  and  of  the  woids  arouses  no  rec- 

1   1/  dic<  i  Repertory,  Cincinnati,  January,  1869, 

'•'  Wernicke,  "  Die  apatische  Sytnptomen  Complex,"  1874. 

:1  Kii-m:i'ii,  ••  Disturbances  of  Speech,"  Ziemssen'a  "  Cycle.,"  vol  \'v.-. 


202  DISEASES   OF   TIIE   BRAIX. 

ollection  in  the  mind  of  an  individual  suffering  from  word-blindness, 
he  is,  of  course,  totally  unable  to  read.  For  the  same  reason  also 
writing  becomes  an  impossibility.  It  sometimes  happens  tbat  though 
the  memory  of  the  appearance  of  printed  or  written  words  is  lost,  the 
memory  of  the  form  of  the  various  letters  may  remain.  In  this  case 
the  patient  can  read  aloud  and  can  copy,  but,  of  course,  does  not  un- 
derstand what  he  has  read  or  written.  It  is  similar  to  a  person  who, 
without  understanding  Latin,  can  read  aloud  Latin  words  and  per- 
haps pronounce  them  faultlessly,  and  yet  not  comprehend  the  meaning 
of  a  single  word  he  has  read. 

Agraphia  is  the  loss  of  the  faculty  of  writing,  and  may  be  either 
sensory  or  motor.  Sensory  agraphia  accompanies  word-blindness,  for 
it  is  manifestly  impossible  to  write  a  word  if  the  memory  of  the  shape 
of  the  letters  is  lost. 

Motor  agraphia  is  the  loss  of  the  memory  of  how  to  make  the 
muscular  movements  necessary  in  guiding  the  pen  or  pencil  in  the 
formation  of  letters.  Motor  agraphia  usually  occurs  simultaneously 
with  motor  aphasia. 

Paraphasia  is  the  loss  of  the  power  of  speaking  coherently. 
There  is  little  or  no  difficulty  in  pronouncing  words,  but  the  words 
uttered  fail  to  express  their  author's  meaning,  and  usually  have  no  sig- 
nificance at  all.  Thus  one  patient  referred  to  his  boots  as  his  "  top- 
sails," while  another,  in  trying  to  tell  the  time,  called  half-past  twelve 
"  half-past  candle-stick." 

Amnesia  is  the  inability  to  voluntarily  recall  memory-pictures  and 
may  involve  any  of  the  special  senses.  A  person  affected  with  this 
form  of  aphasia  finds  it  impossible  to  recollect  the  names  of  people,  or 
of  objects  which  should  be  familiar  to  him.  The  memory-picture  is 
not  destroyed,  as  it  is  in  word-deafness  or  in  word-blindness,  for  the 
forgotten  word  is  immediately  recognized  as  soon  as  it  is  heard  or 
seen,  but  in  most  instances  it  is  immediately  forgotten  again  and  can 
not  be  recalled  by  any  voluntary  effort  of  the  will.  Thus  a  person 
affected  with  amnesic  aphasia  is  shown  a  knife  and  the  question  is  put 
to  him  "What  is  it?"  Immediately  he  shows  by  intelligent  signs 
that  he  knows  what  the  object  is  used  for.  He  will  go  through  the 
motions  of  opening  and  shutting  the  knife,  or  as  if  he  was  cutting  a 
piece  of  stick,  and  you  can  frequently  see  from  the  expression  of  the 
countenance  that  he  is  making  every  effort  to  think  of  the  proper 
name.  You  ask  him:  "Is  it  a  watch?"  "No."  "Is  it  a  hat?" 
"  No."  "  Is  it  a  knife  ?  "  "  Yes,  yes,  a  knife,  a  knife— that  is  it." 
In  a  moment  you  hold  up  the  knife  again  and  ask  him  to  name  it, 
only  to  find  that  he  has  again  forgotten  it. 

Apraxia,  though  not  a  form  of  aphasia,  frequently  occurs  with  it  ; 
particularly  with  word-blindness  and  word-deafness.  Apraxia  is  the 
term  used  to  designate  the  inability  of  an  individual  to  comprehend 


APHASIA,  203 

the  uses  or  imports  of  objects.  This  condition  was  first  described  by 
Kussmaul1  and  more  recently  by  Starr,2  who  reports  nine  cases  of 
apraxia  occurring  with  word-blindness,  in  all  of  which  autopsies  were 
obtained.  To  detect  apraxia  it  is  simply  necessary  to  show  to  the 
person  to  be  tested  several  objects  with  which  all  people  are  more  or 
less  familiar,  and  see  if  he  recognizes  them  and  uses  them  for  the  pur- 
poses for  which  they  were  intended.  If  he  fails  to  do  this,  then 
apraxia  is  present.  Apraxia  is  not  necessarily  confined  to  psychical 
blindness.  There  may  be  apraxia  of  hearing,  of  smell,  of  taste,  and  of 
the  tactile  sense. 

Pathology.— The  lesions  producing  the  different  forms  of  apha- 
sia are  invariably  situated  in  the  left  hemisphere  of  the  brain  in 
right-handed  persons,  and  in  the  opposite  hemisphere  in  left-handed 
persons. 

The  lesion  resulting  in  motor  aphasia  is  situated  in  the  posterior 
part  of  the  inferior  frontal  convolution,  or  Broca's  convolution  as  it 
is  sometimes  called,  and  perhaps  in  the  contiguous  region  of  the  an- 
terior central  convolution  where  the  centres  for  the  lips  and  tongue 
have  been  located.  Lesions  in  the  motor  conducting  paths  below 
this  region  of  the  cortex  also  produce  motor  aphasia,  and,  as  Gow- 
ers 3  points  out,  if  the  lesion  is  immediately  below  the  cortex,  the 
aphasia  becomes  permanent,  since  a  lesion  in  this  position  would 
involve  the  commissural  fibres,  as  well  as  the  fibres  of  the  direct 
speech  tract,  and  thus  there  would  be  no  pathway  for  the  outward 
transmission  of  motor  speech  impulses.  But  if  the  lesion  affects  the 
speech  tract  lower  down,  as,  for  instance,  in  the  internal  capsule, 
then  the  aphasia  will  be  transient,  because  the  motor  impulses  can 
pass  from  the  centre  on  the  left  side  to  the  corresponding  centre  in 
the  right  hemisphere,  thence  through  the  right  internal  capsule  to  the 
lips  and  tongue. 

Word-deafness  is  due,  as  was  first  pointed  out  by  Wernicke,  to  a 
lesion  involving  the  posterior  two-thirds  of  the  first  temporal  convolu- 
tion. It  is  probable  that  a  lesion  of  the  posterior  pari  of  the  second 
temporal  convolution  will  also  result  in  word-deafness. 

Word-blindness   is   produced   by  a  lesion  involving   the   angulai 

gyrus  and  the  sii|ira-inai'L;in;il  convolution. 

The  situation  of  the  lesion  resulting  in  motor  agraphia  has  no1 
been  definitely  determined,  but  recent  investigations  lead  to  the 
belief  thai  it  is  to  be  found  in  the  motor  centres  for  the  lingers  in  the 
posterior  central  convolul ion. 

The  accompanying  diagram  (Fig.  16),  modified  from  Naunyn, 
illustrates  the  position  of  the  lesions  in  the  forms  of  aphasia  jusl  de- 
scribed. 

'  Kttssmaul,  op.  eft.  irr,  dfed.  /.'■•■.,  October  21,  1888. 

iwers,  "  Disease!  of  the  Nervous  System,"  U 


204 


DISEASES   OF   THE   DRAIN7. 


In  paraphasia  we  are  again  indebted  to  the  careful  researches  of 
Wernicke  for  the  first  absolute  knowledge  of  the  situation  of  the 
lesion  resulting  in  this  form  of  aphasia.  Wernicke's  cases  led  him  to 
believe  that  paraphasia  was  due  to  a  lesion  of  the  association  tracts 
between  the  word-speaking  centre  in  the  posterior  part  of  the  inferior 
frontal  convolution  and  the  word-hearing  centre  in  the  temporal  con- 
volutions.      Recent    post-mortem   investigations   confirm   this   view. 


Fig.  16. 


The  lesion  is  usually  found  to  involve  the  island  of  Reil  and  the  parts 
directly  under  it.  The  island  of  Reil  lies  directly  over  the  association 
tract  passing  between  the  word-speaking  and  the  word-hearing  centres. 
Although  the  lesion  is  usually  situated  in  the  position  just  mentioned, 
a  lesion  which  involved  this  association  tract  in  any  part  of  its  course 
would  be  attended  by  the  same  result. 

In  simple  amnesia  the  situation  of  the  lesion  is  not  definitely 
known.  Starr  l  advances  the  theory  that  "auditory  amnesia  is  caused 
by  a  lesion  in  the  association  tracts  leading  to  the  temporal  convolu- 
tions, in  distinction  from  word-deafness  due  to  a  lesion  in  those  convo- 
lutions." This  theory  is  plausible,  but  is  unsubstantiated,  as  its 
author  admits,  by  post-mortem  evidence.  It  would  certainly  seem 
probable,  when  the  appearance  of  an  object  fails  to  arouse  the  recol- 
lection of  its  name,  and  that  feeling  it,  tasting  it,  or  smelling  it,  if 
these  are  possible,  enables  the  individual  to  recall  the  name  desired, 
that  the  lesion  must  be  in  the  association  tracts  and  not  in  the  cortical 
centre.  But  when  it  becomes  impossible  for  an  individual  to  spon- 
taneously think  of  a  word,  of  the  name  of  an  object,  or  of  the  name  of 

1  Starr,  op.  cit. 


APHASIA.  205 

a  person,  in  which  case  neither  the  special  senses  nor  the  association 
tracts  are  necessarily  used  at  all,  then  Starr's  theory  becomes  unten- 
able. The  lesion  in  such  a  case  probably  lies  in  the  same  situation 
as  the  lesion  for  word-deafness — that  is,  in  the  posterior  part  of  the 
first  and  second  temporal  convolutions,  but,  unlike  the  lesion  producing 
word-deafness,  it  does  not  destroy  the  memory-picture,  but  simply 
inhibits  its  regeneration.  The  lesion  producing  apraxia  with  word- 
blindness  is  situated  in  the  temporo-occipital  region.  Apraxia  is  not 
confined  to  psychical  blindness.  There  may  be  apraxia  of  any  of  the 
senses,  but  as  yet  there  is  no  post-mortem  evidence  to  prove  the 
location  of  any  of  these  forms  of  apraxia  except  apraxia  with  word- 
blindness. 

The  following  cases  illustrate  the  different  forms  of  aphasia. 

Cask  I.  Motor  Aphasia. — W.  W.,  aged  forty-one,  entered  the 
New  York  State  Hospital  for  Diseases  of  the  Nervous  System,  August 
22,  1870,  hemiplegic  on  the  right  side,  and  affected  with  ataxic  aphasia. 
In  the  month  of  March,  1868,  as  ascertained  by  Dr.  Cross,  the  resi- 
dent physician  of  the  hospital,  he  was  seized  with  a  dull  pain  in  the 
right  knee,  accompanied  with  numbness,  formication,  and  pricking 
sensations,  limited  to  the  right  foot,  while  general  numbness  of  the 
whole  side  soon  supervened.  These,  with  loss  of  power,  gradually 
extended  and  increased  till  at  the  end  of  two  weeks  the  patient  was 
entirely  hemiplegic.  There  was  at  no  time  any  loss  of  consciousness 
nor  any  mental  aberration.  On  the  11th  of  May  following,  the 
patient  suddenly  lost  the  power  of  speech,  but  his  mind  remained  per- 
fectly clear,  and,  though  he  could  not  utter  a  word,  he  understood 
well  everything  thai  was  said  to  him.  lie  remained  nearly  com- 
pletely aphasic  for  four  months,  being  only  able  daring  that  time  to 
utter  a  few  sounds,  which  could  not  be  interpreted  into  intelligible 
words. 

About  September,  1868,  he  began  to  enunciate  a  lew  words,  at  fust 

very    slowly    ami    indistinctly,    and   gradually   acquired    more   facility. 

When  1  presented  him  before  the  clas^  at  the  Bellevue  Hospital 
.Medical  College,  in  November,  L870,  although  he  could  talk,  his 
power  oi'  co-ordination  was  very  imperfect,  and  many  words  were 
articulated  with  greal  difficulty.  This  trouble  was  chiefly  manifest- 
ed  in  regard   to  labials  and   Unguals,  such   words  as  "truly  rural," 

M  Peter  riper,"  u  baker,"  and  others  (it*  the  kind,  causing  him  to  make 
repeated    efforts    before    he   could    even    imperfectly    pronounce   them. 

There  was  no  paralysis  of  the  tongue,  do  deviation  when  it  was  pro- 
truded, and    but  very  Blight    if  any   paresis  of  the  orbicularis   oris  or 

other  facial  muscles.  The  arm  and  leg  on  the  right  sidcw.iv  pro- 
foundly paralyzed. 

In    this    case    there    was    no    1"--    Of    the    memorj     I'm"    words,    and 

no   difficulty  in   writing.      It   was,  so   far   a-   the   aphasia  was   cm- 


206  DISEASES   OF   THE   BRAIN. 

cerned,  entirely  motor  in  character,  and  accompanied  by  right  hemi- 
plegia. 

My  opinion  is  that  there  had  been  a  lesion  involving  the  motor 
division  of  the  internal  capsule  and  that  the  recovery  from  the  aphasia 
was  due  to  the  fact  that  the  lesion  was  too  low  down  to  affect  the 
commissural  fibres  passing  through  the  corpus  callosum,  and  that  the 
speech  impulses  were  eventually  transmitted  through  this  channel  in 
the  manner  previously  mentioned. 

Case  II.  Amnesia  and  Partial  Motor  Aphasia. — A.  E.,  formerly 
a  bookseller,  consulted  me  in  the  autumn  of  1869  for  what  was  con- 
sidered by  his  friends  to  be,  and  what  probably  was,  softening  of  the 
brain.  Before  any  symptom  of  disease  appeared  he  had  been  noted 
for  his  remarkable  memory,  but  was  now  exceedingly  forgetful, 
especially  as  regarded  words.  Thus  he  had  forgotten  his  first  name, 
and  could  net  tell  me  the  names  of  his  children.  His  conversation 
was  marked  with  great  hesitancy,  from  his  not  remembering  the 
words  he  wished  to  use,  and  there  was,  besides,  marked  difficulty 
of  articulation,  and  some  words  he  could  not  pronounce  at  all.  There 
was  right  hemiplegia,  which  had  gradually  been  getting  worse,  and 
which,  when  I  saw  him,  was  extensive  enough  to  interfere  materially 
with  the  movements  of  his  arm  and  leg.  The  left  side  was  not  affected, 
and  the  tongue  and  face  were  apparently  not  paralyzed.  He  was  sub- 
sequently lost  at  sea  in  the  City  of  Boston. 

This  case,  therefore,  exhibited  both  the  amnesic  and  motor  forms 
of  aphasia,  and  was  accompanied  by  right  hemiplegia.  I  regard  the 
condition  as  being  due  to  thrombosis,  probably  of  the  left  middle  cere- 
bral artery. 

Case  HI.  Word-deafness  with  Auditory  Amnesia,  Word-blind- 
ness, and  Apraxia. — C.  D.,  aged  forty-six,  consulted  me  in  October, 
1886,  for  epilepsy.  He  was  a  Frenchman,  but  had  been  in  America 
many  years  and  spoke  English  fluently.  He  had  had  epileptic  attacks 
for  two  years,  at  first  infrequently,  but  lately  as  often  as  five  or  six 
times  a  day.  Under  treatment  the  attacks  diminished  to  about  one  a 
month.  On  Christmas  Hay,  1888,  he  had  a  sudden  attack  of  hemipa- 
resis  on  the  right  side  of  the  body,  which  was,  however,  unattended 
by  loss  of  consciousness.  Examination  showed  that  he  was  word-deaf 
but  only  for  English  words.  Any  remark  addressed  to  him  in  French 
was  readily  comprehended  and  replied  to  in  French,  but  he  was  totally 
unable  to  understand  anything  said  to  him  in  English.  There  was 
also  amnesia  for  English  words.  When  asked  in  French  to  tell  the 
English  names  of  different  objects  which  were  shown  to  him,  he  could 
not  do  so,  although  he  promptly  named  them  in  French.  He  was  also 
word-blind,  but  only  for  English  words.  French  books  he  could  read 
and  discuss  intelligently,  but  English  books  he  could  not  read  at  all. 
There  was  no  apraxia  present  at  this  time. 


APHASIA.  207 

I  saw  him  again  on  May  5,  1889.  The  right  arm  was  completely- 
paralyzed,  the  right  log  partially  so.  "Word-deafness  was  complete 
for  both  English  and  French  words.  He  could  talk  fairly  well  in  the 
French  language,  but  was  totally  unable  to  understand  a  single  word 
that  was  said  to  him.  Word-blindness  was  now  present  for  both  Eng- 
lish and  French  words.  He  was  therefore  unable  to  read  in  either 
language.  Apraxia  was  also  observed.  He  did  not  know  what  a 
match  was  used  for.  At  his  meals  it  was  noticed  that  he  did  not 
know  what  his  fork  was  for,  although  he  could  have  used  it  perfectly 
well,  as  his  left  arm  was  not  paralyzed  in  the  slightest  degree.  Many 
other  objects,  the  uses  of  which  he  had  formerly  understood,  were 
now  shown  to  be  utterly  unknown  to  him. 

I  saw  him  for  the  last  time  on  July  3d.  There  was  no  change  in 
his  condition  except  that  the  right  leg  had  become  completely  para- 
lyzed. He  died  the  following  month,  but  no  post-mortem  examination 
could  be  obtained. 

Case  IV.  Motor  Aphasia,  Paraphasia,  and  Word-blindness. — 
II.  I.,  a  merchant,  consulted  me  in  August,  1*69,  for  hemiplegia,  with 
inability  to  speak.  While  sitting  at  his  desk,  six  weeks  previously,  he 
suddenly  became  vertiginous,  and  lost  consciousness  for  a  few  moments. 
On  recovering  his  senses,  he  discovered  that  lie  was  paralyzed  on  the 
right  side,  and  that  he  could  not  speak  a  word.  He  was  exceedin^ly 
anxious  to  make  known  some  wish,  and  one  of  his  clerks  brought  him 
paper  and  a  pencil,  but  he  could  not  write  a  letter.  An  alphabet  was 
then  written,  but  he  was  unable  to  select  the  letters  to  form  the  Avords 
he  wanted  to  use. 

A  physician  was  sen*  for,  and  Mr.  I.  was  bled  to  the  extent  of  six- 
teen ounces,  without  any  favorable  result.  He  remained  heraiplegic 
and  completely  aphasic  for  about  two  weeks.  He  then  began  to  walk, 
and  acquired  the  ability  to  say  "what,"  "  certainly,"  and  "saw  my  leg 
off,"  which  he  contracted  into  "sawmelegoff,"  accentuating  strongly 
I  lie  ultimate  syllable.  These  words  he  used  without  apparent  intelli- 
gence,  though  he  clearly  understood  all  that  was  said  to  him,  and 
laughed  at  any  joke  as  heartily  as  ever.  His  condition  was  about  the 
same  when  I  saw  him. 

He  Could  protrude  his  tongue  and  move  it  actively  in  all  direction-, 
but  could  not  articulate  any  words  but  those  mentioned.     Thus,  when 

I  asked   him   to  say   "table,"  he  said  "Certainly";   and  when    1   said 

"Well,  say  it,  then.''  he  exclaimed,  "Sawmelegoff!"     At   the  same 

time,  to  -how  that   he  understood  what  I  said,  he  went  across  the  room 
and    ]>ul   his  hand  on  a  table,  Uttering,  at   the   same  time,  his  full    B1 

of  words,  "what,"  "certainly,"  "sawmelegoff." 

I  then  asked  him  if  he  colli. 1  write;  he  replied,  "Certainly."  I 
placed    paper   before   him,  and    gave   him    a    pen  with    ink,  but   he  wa 

unable  to  write  his  name  a-  I  requested,  although  he  could  use  his 


208  DISEASES   OF   THE   BRAIN. 

fingers  for  other  things  tolerably  well.  I  asked  him  to  draw  a  series 
of  parallel  lines,  and  he  did  so  without  difficulty.  On  my  insisting 
that  he  should  now  make  an  effort  to  write  his  name,  he  made  the 
attempt  with  the  result  shown  in  the  accompanying  woodcut  (Fig. 
17).     I   told  him  that  was  not  his  name,  at  which  he  gesticulated 

Fig.  17. 

violently,  exclaimed  "  Sawmelegoff  !  "  and  gave  me  one  of  his  vis- 
iting-cards. This  gentleman  continued  under  my  care  for  some  time, 
but  with  no  perceptible  change.  He  had  had  two  attacks  of  acute 
articular  rheumatism,  and  had,  when  I  saw  him,  both  aortic  and 
mitral  insufficiency.  My  diagnosis  was  embolism  of  the  left  middle 
cerebral  artery. 

Case  V.  Paraphasia. — Captain  C,  an  officer  of  the  mercantile 
marine,  was  attacked  in  September,  1874,  with  sudden  loss  of  the 
power  of  speech,  attended  with  confusion  of  ideas,  and  vertigo.  He 
soon  recovered,  but  had  several  subsequent  seizures,  characterized  by 
vertigo,  impairment  of  language,  and  slight  delirium.  I  first  saw  him 
on  the  31st  of  October,  and  on  the  28th  of  November  he  went  with  me 
to  the  University  of  New  York,  where  he  was  one  of  the  subjects  of 
my  clinical  lecture  on  aphasia,  delivered  to  the  medical  class.  At  this 
time,  and  for  several  weeks  previously,  he  had  constantly  used  words 
which  were  without  relation  to  the  things  ha  wished  to  name.  Thus, 
if  he  wanted  his  boots,  he  would  ask  for  his  top-sails,  or  would  be  apt 
to  employ  some  other  word  designating  part  of  a  ship.  In  his  con- 
versations with  me  he  continually  exhibited  this  peculiarity.  There 
was  no  want  of  memory  for  any  other  parts  of  speech  than  substan- 
tives. For  instance,  I  held  up  a  penknife  before  him  ;  he  at  once 
said  it  was  to  cut  with,  but  when  I  pressed  him  to  name  it,  he  called 
it  a  "  boat."  A  thermometer  was  an  "  anchor,"  and  a  watch  was  a 
"  capstan."  When  I  asked  him  to  say  "National  Intelligencer"  he  said 
"National  intelligence-office,"  and,  no  matter  how  often  I  repeated 
the  words,  he  always  said  "  National  intelligence-office."  The  reason 
for  this  was  very  obvious  :  he  had  frequently  had  occasion  to  say 
"intelligence-office,"  but  had  probably  never  before  in  his  life  been 
asked  to  say  "National  Intelligencer.''''  After  a  time  he  succeeded  in 
acquiring  the  power  to  utter  the  final  "e  r"  but  then  he  placed  it  in 
the  wrong  position,  and  said  "  National  intelligence-officer."  Syllable 
by  syllable,  he  could  speak  these  words  correctly,  but  they  were  at 
once  forgotten. 

Case  VI.    Paraphasia  and  Agraphia. — Mrs.  L.,  forty-three  years 


APHASIA.  209 

of  age,  consulted  me  in  December,  1888.  About  a  month  previous 
to  my  seeing  her  she  had  awakened  at  her  usual  time  in  the  morn- 
ing and  found  that  her  right  arm  and  leg  were  very  much  weak- 
ened. At  that  time  the  peculiarity  of  her  speech  was  observed  and 
had  continued  ever  since.  She  was  able  to  pronounce  many  words 
perfectly,  while  other  words  were  frequently  mispronounced.  Thus, 
"  pouring  "  was  "  pawling,"  a  "  battery  "  was  a  "  battlewag,"  aud 
"  vaseline  "  was  "  very  green."  There  was  also  a  tendency  to  sub- 
stitute a  word  or  words  in  a  sentence  in  place  of  the  proper  words, 
so  as  to  make  the  sentence  incoherent.  Thus  she  said  that  "she 
had  just  been  to  peppermint,"  meaning,  however,  that  she  had  just 
been  to  church.  "Half-past  twelve"  she  called  "  half  -past  candle- 
stick." She  was  also  unable  to  write  a  single  word.  With  a  pen  or 
a  pencil  she  could  draw  fairly  well,  and  could  copy  letters  with  con- 
siderable accuracy. 

Case  VII.  Motor  Aphasia  and  TTord-blindness. — G.  E.,  a  noted 
physician  of  this  city,  was  suddenly  stricken  with  apoplexy.  On  re- 
gaining his  consciousness  it  was  observed  that,  although  he  compre- 
hended everything  that  was  said  to  him,  he  could  not  speak  a  single 
word  spontaneously,  neither  could  he  repeat  words  when  asked  to 
do  so.  Thinking  that  he  might  be  able  to  express  his  thoughts  by 
means  of  letters  formed  into  words,  an  alphabet  was  brought  to 
him,  but  he  could  not  arrange  the  letters  so  as  to  form  words.  lie 
had  lost  the  visual  memory  of  the  letters.  When  words  were  formed 
from  the  letters  and  shown  to  him,  he  failed  to  comprehend  them. 
He  had  therefore  lost  the  visual  memory  for  words  also.  This  con- 
stitutes a  perfect  example  of  word-blindness  accompanied  by  motor 
aphasia. 

(ask  VIII.  Amnesia  and  Agraphia. — During  the  winter  of 
1808-09  a  man  came  to  my  clinic,  at  the  Bellevue  Hospital  ."Medical 
College,  who  was  aphasie,  and  from  whose  friends,  his  own  gest- 
ures, and  the  few  words  he  could  speak,  I  obtained  the  following 
history  :  Some  months  previously  he  had  been  working  in   a  stone- 

quarry,  and  was  struck  by  some  piece  Of  machinery  on  the  left  side  of 
the  head,  at  about  the  junction  of  the  frontal  with  the  temporal  bone. 

For  a  short  time  he  was  unconscious,  recovering,  however,  without 
paralysis,  but  with  Loss  of  Ihe  memory  of  words.  When  he  came 
under  my  observation  he  was  very  intelligent,  comprehended  every 
word  s aid  to  him,  and  mad-  repeated  and  persistent  efforts  to  talk,  but 

be  COold    not    utter  a   word    spontaneously    beyond    "yes"   and    "  no," 

which  he  always  used  correctly.  Thus,  when  [asked  him  where  he 
was  born,  he  became  much  excited,  gesticulated  violently,  and  appar- 
ently made  every  effort  to  tell  me.  The  perspiration  stood  out  in 
large  drops  on  his  forehead,  but  do  Bound  came  from  his  lips.  Then 
the  following  conversation  took  place:  "Were  J  00  born  in  l'rus- 
16 


210  DISEASES   OF   THE   BRAIN. 

eia?"  "No."  "In  Bavaria?"  "No."  "In  Austria?"  "No." 
"In  Switzerland?"  "Yes,  yes,  yes — Switzerland,  Switzerland,"  at 
the  same  time  laughing,  and  moving  his  hands  actively  in  all  direc- 
tions.    He  could  pronounce  words  well,  but  could  not  wrrite. 

I  took  occasion  to  speak  at  length  on  the  subject  of  aphasia,  and 
gave  it  as  my  opinion  that  thore  had  been  a  fracture  of  the  internal 
table  of  the  skull,  and  that  a  fragment  of  bone  was  pressing  on  the 
posterior  and  lateral  part  of  the  anterior  lobe.  Prof.  Say  re  was  pres- 
ent, and  I  advised  him  to  trephine  the  patient,  with  the  view  of  elevat- 
ing any  depressed  piece  of  bone,  and  restoring  the  normal  function  of 
that  part  of  the  brain.  The  operation  was  performed  a  few  days 
afterward,  the  patient  being  placed  under  the  influence  of  ether.  The 
internal  table  was  found  to  be  fractured,  and  a  splinter  was  pressing 
on  the  anterior  central  convolution.  It  was  removed,  and,  as  soon  as 
the  patient  emerged  from  the  anesthetic  condition,  he  spoke  perfectly 
well. 

Case  IX.  Motor  Aphasia  and  Agraphia,  followed  by  Parapha- 
sia.— J.  H.,  a  captain  of  a  coasting-vessel,  consulted  me  in  November, 
1864,  for  difficulty  of  speech  with  which  he  had  been  affected  for  sev- 
eral months.  Upon  inquiry,  I  ascertained  that  one  morning  early  he 
had  been  called  from  his  bed  upon  some  duty  connected  with  his  ves- 
sel ;  that  he  had  risen  rather  hastily  and  gone  on  deck  ;  that  while 
giving  an  order  he  suddenly  became  very  dizzy,  and  fell,  unconscious. 
He  soon  regained  his  senses,  but  found  that  he  was  paralyzed  on  the 
right  side,  and  bad  lost  the  ability  to  speak.  It  was  subsequently 
ascertained  that  he  had  also  lost  the  ability  to  write.  He  could  under- 
stand all  that  was  said  to  him  and  could  read.  His  agraphia  and 
aphasia  were  therefore  both  motor.  He  soon  afterward  reached  port, 
and  remained  at  home  for  three  months,  during  which  period  the 
paralysis  disappeared  almost  entirely,  and  he  reacquired  the  ability  to 
speak  and  to  write. 

He  then  went  to  sea  again  as  a  passenger  to  Cuba,  and  while  in 
Havana  had  another  attack  similar  to  the  first,  but  without  paralysis  of 
motion,  though  there  was  loss  of  sensibility  on  the  right  side.  The 
memory  for  words  was  entirely  destroyed,  though  he  could  pronounce 
distinctly  any  word  he  was  told  to  say,  if  he  did  not  allow  too  long  a 
period  to  elapse  between  the  direction  and  the  response.  About  four 
months  after  his  last  seizure  he  consulted  me. 

At  this  time  he  could  say  a  few  words,  and  he  employed  them  to 
express  all  his  ideas,  assisting  himself  with  very  energetic  gestures, 
which,  however,  were  rarely  expressive  of  his  thoughts.  The  words 
he  thus  constantly  used  were  "  sifi,"  which  signified  both  "  yes  "  and 
"no,"  and  "time  of  day,"  which  he  employed  when  he  had  any  other 
answer  than  a  simple  affirmative  or  negative  to  give.  Besides  these 
expressions,  he  had  an  oath,   "  Hell  to  pay  ! "  which  he  ejaculated 


APHASIA.  211 

whenever  he  did  not  succeed  in  making  himself  understood,  and  some- 
times without  any  such  exciting  cause.  These  were  the  only  expres- 
sions he  could  originate,  but  he  could  pronounce  distinctly  any  word 
he  was  told  to  say,  and  even  as  many  as  three  short  successive  words. 
When  told  to  write,  he  took  the  pen,  and,  on  my  telling  him  to  give 
me  his  name  and  address,  wrote  "  Time  of  day,"  and  then,  seeing  that 
that  was  not  the  correct  answer,  immediately  followed  it  with  "  Hell 
to  pay  !  "  On  my  remarking  to  him  that  he  had  given  me  wrong 
information,  he  immediately  wrote  "  sin'."  Any  word,  however,  which 
I  told  him  to  write,  he  did  without  any  difficulty,  and  thus  I  obtained 
several  long  sentences  from  him. 

From  his  brother,  who  came  with  him,  I  obtained  the  facts  in  his 
history  I  have  mentioned.  Examining  his  heart,  I  found  that  he  had 
a  strong  systolic  murmur,  and  was  told  by  his  brother  that  he  had  had, 
fifteen  years  ago,  a  first  attack  of  acute  articular  rheumatism,  which 
had  been  followed  by  several  other  attacks. 

Many  other  cases  of  aphasia  have  come  under  my  observation,  but 
it  is  scarcely  necessary  to  mention  them  in  detail,  as  they  present  no 
features  differing  in  any  material  point  from  those  cited. 

It  will  be  observed,  however,  that  simple  uncomplicated  cases  of 
any  one  form  of  aphasia  are  uncommon.  Motor  aphasia  occurs  more 
frequently  than  any  other  form,  and  is  more  liable  to  occur  independ- 
ently of  any  other  variety  of  aphasia.  The  reason  for  this  is  obvious. 
Motor  aphasia  frequently  accompanies  ordinary  hemiplegic  attacks 
resulting  from  a  cerebral  hemorrhage,  involving  the  anterior  two- 
thirds  of  the  internal  capsule.  In  such  a  case  only  the  motor  tract  is 
injured,  and,  of  course,  only  motor  aphasia  is  produced.  This  aphasia 
is  usually  transient,  which  is  in  direct  contrast  to  motor  aphasia  of 
cortical  or  immediately  subcortical  origin.  On  the  other  band,  word- 
deafness,  word-blindness,  and  amnesia  are  more  frequently  caused  by 
embolism  or  thrombosis  of  an  artery  which  results  in  the  softening  of 
quite  an  extensive  area  of  the  cortex.  It  is  for  this  reason  that  word- 
blindness  and  word-deafness  are  so  Frequently  associated. 

A^  to  the  causes,  the  prognosis,  diagnosis,  morbid  anatomy,  and 
pathology,  they  have  been  sufficiently  considered  in  the  remarks  made, 

and  the    treatment     is  of    COUTSe    that  of    the   pathological  condition  to 

which  it  is  due,  whether  this  he  cerebral  hemorrhage,  embolism,  throm- 
bosis, softening,  hysteria,  wounds,  the  bites  of  poisonous  serpents,  syph- 
ilis, or  Other  cause.      One  point,  however,  should    be  mentioned  in  this 

connection,  and  that  is  that  < stant  efforts  should  be  made  to  develop 

the  uninjured  speeeh-ceiit  re,  and  to  exercise  the  VOCal  organs  by  con- 
stant attempts  to  >pe;ik.  The  application  of  the  galvanic  or  faradaic 
currents  to  the  tongue  and  other  muscles  concerned  in  articulation  is 

a  measure  of  usefulness. 


212  DISEASES   OF   THE   BRAIN. 

CHAPTER  Vni. 

ACUTE  CEREBRAL  MENINGITIS. 

By  acute  cerebral  meningitis  is  understood  inflammation  of  two 
membranes  of  the  brain — the  pia  mater  and  arachnoid.  Some  writers 
have  made  the  attempt  to  discriminate  between  inflammation  of  the 
arachnoid  and  inflammation  of  the  pia  mater,  but  there  are  no  diagnostic 
marks  by  which  such  a  distinction  can  be  made,  and  we  find  from  post- 
mortem examination  that  neither  membrane  can  be  inflamed  without  the 
other  participating  in  the  morbid  process.  Inflammation  of  the  dura 
mater  is  never  included  under  the  term  meningitis. 

The  ancients  made  no  distinction  between  the  several  inflammatory 
affections  of  the  intra-cranial  organs,  but  comprehended  them  all  in  one 
disease,  which  they  called  frenzy — (ppijv,  the  brain.  Morgagni,  however, 
showed  that  the  membranes  of  the  brain  were  the  parts  generally 
involved,  and  gave  a  very  accurate  account  of  the  phenomena  of  an 
attack  of  acute  meningitis.  Since  then,  Rostan,  Lallemand,  Andral, 
Bouillaud,  and  others,  have  added  to  our  knowledge. 

Symptoms. — The  symptoms  of  acute  cerebral  meningitis  may  be 
divided  into  three  groups,  arranged  in  chronological  order:  the  stage  of 
invasion,  the  stage  of  excitation,  and  the  stage  of  collapse. 

1.  The  Stage  of  Invasion. — The  most  prominent  initiatory  symp- 
tom is  headache,  which  may  be  diffused  or  confined  to  a  limited  part  of 
the  head.  When  this  latter  is  the  case,  the  frontal  region  is  more  gen- 
erally its  seat;  next  in  order  of  frequency  is  the  occipital,  and  next  the 
temporal.  At  the  same  time  the  face  is  flushed,  the  eyes  are  red  and 
suffused,  arid  there  is  a  decided  elevation  in  the  temperature  of  the  head, 
which  is  not  only  felt  by  the  patient,  but  may  be  perceived  by  the  hand 
of  the  physician.     Vomiting  is  generally  present. 

As  might  be  expected,  these  symptoms  are  accompanied  by  fever. 
This,  however,  rarely  runs  high,  so  far  as  the  force  or  the  frequency  of 
the  pulse  is  concerned,  or  as  regards  the  heat  of  the  skin.  It  is  mainly 
characterized  by  restlessness  and  insomnia.  Occasionally  there  is  a 
tendency  to  somnolence. 

This  stage  may  last  a  few  days  or  only  a  few  hours,  or  may  be  so 
slight  as  not  to  attract  attention.  In  general  features  it  resembles 
the  prodromatic  stage  of  cerebral  congestion. 

2.  The  Stage  of  Excitement. — A  chill  ushers  in  this  stage, 
and  an  increase  in  the  intensity  of  several  of  the  symptoms  of 
the  first  stage  and  the  development  of  others  soon  take  place. 
Thus  the  fever  becomes  higher,  the  skin  hotter,  and  the  tempera- 
ture of  the  body  is  elevated  several  degrees — the  thermometer  rising 


ACUTE   CEREBRAL   MENINGITIS.  213 

as  high  as  105°,  106°,  and  sometimes  to  107°.  The  pulse  is  fre- 
quent— rising  to  120,  or  even  160 — quick  and  hard,  and  the  face  be- 
comes redder  than  in  the  first  stage.  The  pain  in  the  head  augments 
in  violence,  and  is  increased  by  pressure  on  the  scalp,  or  even  the 
slightest  movement. 

The  eyes  are  bright,  the  pupils  contracted  and  painfully  sensitive  to 
light.  The  hearing  becomes  morbidly  acute,  loud  noises  cause  great 
agony,  and  even  slight  sounds  are  unbearable.  The  general  sensibility 
of  the  body  is  increased,  and  hence  the  patient  is  rendered  uncomfort- 
able by  the  contact  of  the  bedclothes  with  the  skin.  Delirium  is  gen- 
erally present  from  the  first,  and  is  often  of  furious  character.  Hallu- 
cinations of  sight  and  hearing  are  almost  constant,  and  the  irrationality 
of  the  ideas  is  marked  by  the  incoherence  of  the  speech.  The  patient 
when  awake  is  continually  talking,  gesticulates  violently,  and  weeps 
and  laughs  alternately  over  imaginary  evils.  It  is  sometimes  necessary 
to  use  restraint  to  prevent  him  injuring  himself  or  others,  and  tho 
attendants  should  always  be  prepared  for  any  emergency  of  the  kind. 
As  the  disease  advances,  the  delirium  becomes  more  subdued,  and  the 
patient  may  exhibit  some  evidences  of  sanity. 

Even  when  there  is  no  delirium,  as  occasionally  happens,  the  influ- 
ence of  the  morbid  action  over  the  mind  is  shown  in  the  irritability  of 
the  patient,  and  the  change  which  he  undergoes  in  character  and  dis- 
position. 

Convulsions  rarely  occur  in  adults,  but  motility  generally  is  never- 
theless disordered.  The  limbs  are  in  almost  continual  action,  as  are 
likewise  the  jaw  and  the  eyelids.  Twitchings  of  the  facial  and  other 
muscles,  such  as  those  of  the  forearm,  are  usually  well  marked,  and 
occasionally  there  are  irregular  movements  of  the  eyeballs.  Convul- 
sions, when  they  occur,  may  be  either  clonic,  or  tonic,  or  both.  Thus 
there  may  be  a  gradually-increasing  rigidity  of  some  muscles,  followed 
by  relaxation  and  disordered  movements.  Sometimes  there  is  opis- 
thotonos as  well  marked  as  in  some  cases  of  tetanus.  Hemiplegia  or 
paraplegia  may  occur,  but  are  infrequent  complications.  I  have  seen 
two  cases  in  which  one  lateral  half  of  the  body  was  paralyzed  during 
the  whole  course  of  the  disease. 

Contractions  of  the  limbs  sometimes  take  place,  and  may  be  con- 
fine I  to  one  side  or  to  a  single  limb.  In  this  ease  the  forearm  is  usu- 
ally strongly  flexed  on  the  arm. 

The  muscles  of  organic  life  participate,  and  the  bowels  an-  obsti- 
nately const  ipated.  There  may  be  difficulty  of  swallowing,  from  Bpasm 
of  the  pharynx,  and  irregularity  of  breathing,  from  implication  of  the 

respiratory  musclt 

The  mo8l  characteristic  symptom  of  this  stage  is,  however,  the 
obstinate  and  violent  cephalalgia,  of  which  mention  has  already  been 
made,  and  yet  there  arc  oases  in  which  it  is  entirely  absent  from  first 


214  DISEASES  OF  THE  BRAIN. 

to  last.  Several  such  instances  have  been  under  my  own  charge,  and 
post-mortem  examination  has  verified  the  existence  of  the  evidences 
of  meningitis.     This  stage  lasts  from  a  few  days  to  two  weeks. 

3.  The  Stage  or  Collapse. — The  beginning  of  this  stage  is  marked 
by  the  occurrence  of  somnolence,  which  often  shows  a  tendency  to  pass 
into  coma,  and  by  a  subsidence  of  the  delirium  and  muscular  agitation. 
There  are  times,  however,  during  which  the  stupor  remits  in  profundity, 
and  the  patient  appears  to  be  somewhat  conscious  of  his  condition,  but 
these  periods  only  occur  in  the  first  part  of  the  third  stage.  Ere  long 
the  coma  becomes  constant. 

Paralysis  then  supervenes,  and  is  first  manifested  in  the  ocular  or 
facial  muscles.  Thus  from  paralysis  of  one  of  the  muscles  of  the  eye- 
ball strabismus  ensues,  or  the  upper  eyelid  may  drop  from  paralysis  of 
the  levator  palpebral  superioris.  The  pupils  dilate  and  become  insensi- 
ble to  light,  and  the  mouth  is  drawn  to  one  side  from  implication  of  the 
muscles  of  the  face.  Before  long  the  contractions  of  the  limbs  relax, 
and  paralysis  takes  place.  The  sphincters  of  the  bladder  and  rectum 
also  lose  their  power,  and  the  urine  and  fasces  escape  involuntarily. 
The  pulse  becomes  slow  and  irregular,  but  the  temperature,  as  Jaccoud 
has  shown,  and  as  I  have  lately  verified  in  several  instances,  does  not 
fall.  Some  authors  regard  this  reduction  in  the  frequency  of  the  pulse 
while  the  heat  of  the  body  remains  high,  as  pathognomonic.  The  in- 
sensibility becomes  more  and  more  profound,  and  the  patient  dies  in  a 
state  of  coma,  sometimes  from  asphyxia  produced  by  paralysis  of  the 
respiratory  muscles,  but  generally  from  the  gradual  engorgement  of  the 
lungs,  and  with  a  bodily  temperature  as  high  as  at  any  other  period  of 
the  disease. 

Such  is  the  ordinary  course  of  an  attack  of  simple  acute  cerebral 
meningitis  occurring  in  a  young  and  healthy  person.  Though  it  is  cer- 
tainly true,  as  post-mortem  examinations  have  shown,  that  the  mor- 
bid process  may  be  general  or  limited  to  the  convex  or  basilar  surface 
of  the  brain,  or  to  the  ventricular  lining,  yet  during  life  the  distinction 
cannot  be  made,  mainly  for  reasons  which  will  be  given  under  the  head 
of  pathology.  But  there  are  modifications  often  met  with  which  require 
consideration.  Of  these,  epidemic  cerebro-spinal  meningitis,  though 
scarcely  to  be  considered  a  disease  of  the  nervous  system,  and  tubercu- 
lar meningitis,  will  be  discussed  under  other  heads,  but  the  differences 
due  to  acute  rheumatism  and  old  age  may  very  properly  be  noticed  in 
the  present  connection. 

RHEUMATIC    MENINGITIS. 

Under  the  name  of  cerebral  rheumatism,  several  very  different  affec- 
tions of  the  brain  supervening  during  the  course  of  acute  articular 
rheumatism  have  been  embraced.  The  relation  of  rheumatism  to  stifch 
secondary  diseases  has  long  been  recognized,  but  very  great  confusion 


ACUTE   CEREBRAL   MENINGITIS.  215 

has  existed  in  regard  to  the  exact  nature  of  the  morbid  processes  set 
up  in  the  brain  and  its  membranes.  That  meningitis  may,  however,  be 
one  of  these  conditions,  appears  to  be  quite  certain.  Gintrac '  has  col- 
lected twenty-one  cases  of  cerebral  meningitis  the  result  of  rheumatism, 
or  at  least  occurring  in  conjunction  with  that  disease,  the  existence  of 
which  was  established  by  post-mortem  examination.  Oulie 3  con- 
tributes four  others,  and  many  more  are  to  be  found  in  medical  treatises 
and  periodicals. 

Although  I  have  witnessed  a  number  of  cases  of  what  in  former 
editions  of  this  work  was  designated  cerebral  rheumatism,  I  have  only 
had  one  case  in  which  the  existence  of  meningitis  as  a  consequence  of 
rheumatism  was  demonstrated  by  post-mortem  examination. 

The  membranes  of  the  brain  are  most  liable  to  be  affected  during 
the  latter  stage  of  an  attack  of  acute  rheumatism,  but  there  seems  to  be 
no  doubt  that  the  cerebral  disease  in  question  may  supervene  at  any 
time  during  the  course  of  the  primary  disease,  and  that  it  sometimes 
has  all  the  appearance  of  being  a  true  metastasis.  The  symptoms  which 
indicate  the  supervention  of  cerebral  meningitis  are  delirium,  convul- 
sions, or  more  frequently  choreiform  movements  in  the  limbs,  tremor, 
especially  about  the  lips  and  muscles  of  the  face,  paralysis  in  various 
parts  of  the  body,  and  stupor.  Pain  and  vomiting,  which  are  such  con- 
stant features  of  ordinary  meningitis,  are  rarely  present  in  the  rheu- 
matic form  of  the  affection.  The  bodily  temperature  is  not  elevated 
more  than  three  or  four  degrees  above  the  normal  standard.  Toward 
the  last,  coma,  if  already  present,  becomes  more  profound,  or  if  not, 
makes  its  appearance,  and  death  ordinarily  ensues.  Occasionally,  how- 
ever, recovery  takes  place.' 

SENILE    MENINGITIS. 

In  old  persons,  the  symptoms  of  acute  meningitis  are  rarely  so 
pronounced  as  in  individual  >  of  middle  age.  The  affection  comes  on 
more  gradually,  and  may  have  made  considerable  progress  before'  its 
existence  is  Buspected.  There  is  little  or  no  pain,  do  fever,  and  no 
gastric  or  intestinal  derangement.  The  mental  symptoms  are  very 
similar  to  those  due  t<>  softening.  The  patient  has  imperfect  articu- 
lation, his  memory  is  impaired,  and  he  does  things  which  -how  that  he 
is  not  in  his  right  mind.     The  delirium  is  of  the  low  muttering  kind, 

1  Op.  cit,,  tome  iii.,  p.  11. 

8  "Du  rheumatisme  cerebral*"    These  de  Paris  1868. 

3  In  a  very  valuable  memoir  on  "Cerebral  Rheumatism,"  just  published,  Prof.  Pa 
Costa1  has  given  the  details  of  twelve  cases  in  which  oerebral  symptoms  supervened  dur- 
ing the  cm.  alar  rheumatism,    Dr.]  opinion  that  all  i 
it  Is  called  cerebral  rheumatism  are  nol  characterized  by  the  presence  of  menin 
and  the  results  of  the  post-mortem  examinations  which  be  obtained  from  his 

1  American  Journal  o/the  Medical  Sciences,  Juiuary,  ls7.\  p.  17. 


216  DISEASES   OF  TIIE   BRAIN. 

and  there  is  a  tendency  to  coma  even  in  the  first  stage.  There  is  a 
more  or  less  general  paresis  in  all  the  limbs,  and  subsultus  is  com- 
monly present.     Death  is  usually  due  to  pulmonary  engorgement. 

Causes. — Among  the  predisposing  causes  of  acute  cerebral  menin- 
gitis, age  is  first  to  be  considered.  Guersant '  asserts  that  the  period  of 
life  between  sixteen  and  forty-five  is  that  during  which  acute  menin- 
gitis is  most  liable  to  occur,  not  including  children,  who  are  far  more 
prone  to  the  disease  than  adults.  Rilliet  and  Barthez2  have,  however, 
shown  that  very  young  infants  are  not  so  subject  to  simple  acute  menin- 
gitis as  children  of  from  five  to  eleven  years  of  age.  The  very  oppo- 
site opinion  is  expressed  by  Drs.  Meigs  and  Pepper.3 

Thirteen  cases  of  acute  simple  meningitis  have  come  under  my  ob- 
servation.    Of  these,  all  were  between  the  ages  of  thirty  and  forty. 

Men  are  more  subject  to  it  than  women.  Of  my  cases,  ten  were 
males  and  three  females.  Parent-Duchatelet  and  Martinet,4  however, 
think  women  are  more  predisposed  to  the  affection  than  men. 

Temperature,  either  very  high  or  very  low,  predisposes  to  acute 
meningitis.  Eight  of  the  cases  under  my  care  occurred  in  summer  and 
five  in  winter. 

Certain  professions  and  habitudes  appear  to  favor  the  occurrence 
of  the  disease.  Among  the  former  are  all  those  which  require  the  head 
to  be  exposed  to  strong  and  direct  heat ;  among  the  latter  are  exces- 
sive intellectual  exertion,  and  abuse  of  alcoholic  liquors.  Tertiary 
syphilis,  gout,  and  rheumatism  are  likewise  predisponents. 

Larrey5  states  that  in  the  retreat  of  the  French  army  from  Russia, 
the  soldiers,  who  had  endured  the  most  terrible  sufferings  from  hunger 
and  cold,  were  attacked,  on  their  arrival  in  Konigsberg,  where  they  had 
ample  food  and  warm  quarters,  with  cerebral  meningitis,  which  in  gen- 
eral proved  fatal.     This  result  was  probably  due  to  the  operation  of 

tainly  support  this  view.  But  in  Case  I. — a  very  characteristic  instance — the  brain  was 
not  examined ;  Case  V.  recovered ;  in  Case  VI.  the  brain  was  not  examined ;  in  Case 
VIII.,  also  a  marked  case,  in  which  there  were  flushing  of  the  face,  occasional  spasmodic 
contractions  of  the  facial  muscles,  contracted  pupils,  undulatory  motions  of  the  body,  and 
tossing  of  the  arms,  an  examination  was  refused  ;  in  Case  IX.,  in  which  there  were  mental 
symptoms,  facial  paralysis,  ptosis,  and  hemiplegia,  the  patient  recovered ;  in  Case  XI.  re- 
covery took  place,  as  it  did  also  in  Case  XII.,  so  that  in  only  six  were  there  post-mortem 
examinations  of  the  encephalon. 

Dr.  Da  Costa  does  not  doubt  the  existence  of  rheumatic  meningitis,  but  he  contends, 
and  I  think  successfully,  that  all  cases  of  cerebral  disorder,  originating  during  the  course 
of  articular  rheumatism,  are  not  cases  of  meningitis,  and  that  in  some  cases  there  are 
actually  no  abnormal  post-mortem  appearances. 

1  Art.  "Meningite,"  in  "  Dictionnaire  de  Medecine,"  Paris,  1839. 

8  "Traite  des  maladies  des  enfants,"  Paris,  1853. 

8  "  A  Practical  Treatise  on  the  Diseases  of  Children,"  Philadelphia,  1870,  p.  464. 

4  "  Recherches  sur  l'inflamination  de  l'arachnoide,"  Paris,  1821. 

6  "Memoires  de  chirurgie  militaire  et  campagucs,"  Paris,  1817,  tome  iv.,  p.  139. 


ACUTE   CEREBRAL  MENINGITIS.  217 

many  causes  besides  prolonged  exposure  to  a  low  temperature,  among 
which  the  sudden  removal  of  the  mental  tension  maintained  by  the 
exigencies  of  the  situation  in  which  the  army  was  placed,  was  not  the 
least. 

Of  exciting  causes,  injuries  of  the  head  from  falls  or  blows  of  differ- 
ent kinds  stand  first.  Next  is  exposure  to  the  direct  rays  of  the  sun, 
or  other  source  of  great  heat,  and  then  recession  of.  an  exanthematous 
affection,  such  as  scarlatina,  measles,  or  erysipelas,  and  the  irritation  of 
dentition,  or  intestinal  worms. 

Acute  cerebral  meningitis  sometimes  prevails  epidemically.  Such 
was  the  case  with  the  series  of  instances  which  came  under  Larrey's 
observation,  and  others  have  been  noted. 

Diagnosis. — Acute  meningitis  may  be  confounded  with  partial  or 
circumscribed  encephalitis,  but  the  distinction  is  made  by  considering 
that  in  the  latter  the  headache  is  less  severe,  the  delirium  less  marked, 
and  the  convulsions  and  contractions  weaker.  Moreover,  the  febrile 
excitement  is  much  greater  in  acute  meningitis  than  in  partial  enceph- 
alitis, and  the  whole  disease  more  pronounced. 

The  meningitis  of  the  aged  bears  a  considerable  degree  of  resem- 
blance to  cerebral  softening;  but  the  fact  that  the  first-named  affection 
is  more  rapid  in  its  progress,  and  is  not  preceded  by  symptoms  due  to 
other  morbid  conditions,  will  generally  enable  the  practitioner  to  make 
a  correct  diagnosis. 

From  delirium  tremens  it  may  he  distinguished  by  the  history  of 
the  case,  by  the  greater  tendency  to  insomnia  exhibited  in  alcoholism, 
and  by  the  general  character  of  the  delirium.  The  febrile  excitement 
of  acute  meningitis,  the  pain  in  the  head,  the  heat  of  the  skin,  the  ab- 
sence of  clammy  perspiration,  and  the  increased  temperature,  as  shown 
by  the  thermometer,  are  conclusive  diagnostic  marks. 

From  typhoid  fever  meningitis  is  diagnosticated  by  the  existence 
in  the  former  of  meteorism,  abdominal  tenderness,  and  petechia*,  by 
the  facts  that  the  headache  and  febrile  excitement  are  less,  and  that 
diarrlxea  is  present  and  vomiting  is  not. 

Prognosis. — This  is  always  grave.  Occasionally  death  takes  place 
in  a  very  few  hours,  and  generally  before  the  tenth  day.  When  the 
disease  is  prolonged  beyond  this  latter  period,  the  prognosis  becomes 
more  favorable.  The  occurrence  of  strabismus  or  other  paralytic 
affection  lessens  the  hope  of  a  favorable  termination.  Prof.  Flint, 
however,  has  oited  two  oast  is  occurring  in  the  hospital  practice  of 
himself  and  Dr.  Thomas,  in  which  there  were  strabismus,  hemiplegia, 
and  coma,  both  of  which  recovered.     Be  also  oites  another  case  in 

which  (here  W08  Strabismus,  and    in  which  recovery  took    place.      llie- 

cough  is  an  unfavorable  event. 

<  >f  the  thirteen  cases  observed  by  myself,  eleven  died.    In  all  of  these 

fatal    eases    there  was   Si  raliismus.      In   the   two   eases  which  recovered 


218  DISEASES   OF  THE   BRAIN. 

there  was  no  squinting'.  The  deaths  in  the  fatal  cases  all  occurred  be- 
fore the  tenth  day,  and  two  took  place  before  the  end  of  the  third  day. 

Morbid  Anatomy. — If  death  occurs  during  the  second  stage  of  the 
disease,  the  most  marked  appearance  found  in  the  membranes  is  red- 
ness from  increased  hyperaemia.  If,  however,  it  is  delayed  till  the  third 
stage,  thickening  and  opacity  of  the  membranes  and  adhesions  to  each 
other,  and  of  the  pia  mater  to  the  brain,  and  effusion  of  serum,  are  the 
prominent  features.  In  a  case  in  which  I-  made  a  post-mortem  exami- 
nation in  the  summer  of  1870,  and  which  was  caused  by  the  great  heat 
of  the  season,  there  was  an  extensive  collection  of  bloody  serum  in  the 
cavity  of  the  arachnoid,  and  the  pia  mater  was  so  adherent  as  to  bring 
with  it  a  layer  of  the  gray  matter  of  the  brain  as  it  was  stripped  off. 

The  fluid  may  consist  solely  of  pus,  or  this  may  be  mingled  with 
serum  in  all  proportions.  The  pus,  with  the  fibrine  of  the  exuded  serum, 
often  forms  thin  plates  of  membraniform  texture,  which  are  scattered 
over  the  surface  of  the  inflamed  region  or  may  entirely  cover  it,  and 
which  are  of  the  nature  of  false  membranes. 

If  death  has  taken  place  late  in  the  course  of  the  disease,  evidences 
of  the  implication  of  the  cerebral  substance  will  generally  be  discerned. 
These  consist  in  the  gray  matter  becoming  of  a  pinkish  color,  and  the 
white,  when  cut,  showing  numerous  puncta  vasculosa.  The  ventricles 
rarely  contain  any  considerable  amount  of  fluid,  and  are  often  entirely 
empty.     The  latter  was  the  case  in  the  instance  above  mentioned. 

Pathology. — The  symptoms  of  the  first  and  second  stages  are  due 
to  congestion;  those  of  the  third  mainly  to  effusion  and  consequent 
pressure. 

An  important  question  connected  with  the  pathology  relates  to  the 
determination,  from  the  sj'mptoms,  what  part  of  the  brain  is  the  seat 
of  the  lesion.  The  convex  surface  of  the  hemispheres  is  intimately 
related  to  the  purely  intellectual  functions  of  the  brain  and  to  the  fac- 
ulties of  motion  and  sensibility,  while  the  under  surface,  or  base,  is 
connected  more  with  the  special  senses  and  is  closely  in  apposition  with 
the  various  cranial  nerves.  Thus,  if  the  inflammation  be  strictly  lim- 
ited to  the  upper  surface  of  the  brain,  the  predominant  symptoms  are 
those  involving  intellectuality,  and  consequently  there  is  delirium 
marked  by  incoherence  of  ideas  and  irrationality  of  language.  There 
are  muscular  contractions,  spasms,  convulsions,  and  paresis  or  paraly- 
sis of  various  groups  of  muscles  in  proportion  to  the  extent  of  the  in- 
flammation over  the  motor  areas.  Disturbances  of  sensibility,  such  as 
headache,  tactile  and  thermic  anaesthesia,  hyperesthesia,  analgesia,  and 
paresthesia,  are  frequently  observed.  If,  on  the  contrary,  the  base  of 
the  brain  alone  is  affected,  the  resulting  symptoms  are  principally  due 
to  the  implication  of  the  cranial  nerves.  Thus  optic  neuritis  is  a  symp- 
tom frequently  observed,  and  can  usually  be  detected  in  a  few  days 
after  the  onset  of  the  meningitis  by  a  careful  ophthalmologics!  exami- 


ACUTE   CEREBRAL    MENINGITIS.  219 

nation.  The  third  nerve  is  frequently  affected,  producing  strabismus 
and  ptosis.  The  facial  nerves  are  occasionally  implicated  in  one  or 
more  of  their  branches,  and  the  auditory  nerve,  which  accompanies  the 
facial  in  a  part  of  its  course,  is  likewise  prone  to  suffer.  When  these 
two  nerves  are  affected,  facial  paralysis  and  deafness  result.  If  the 
hypoglossal  nerve  on  one  side  only  is  inflamed,  the  tongue  will  be  para- 
lyzed on  one  side,  and  will  deviate  toward  the  side  of  the  lesion.  If 
both  nerves  are  affected,  the  tongue  can  only  be  protruded  with  great 
difficulty,  or  else  not  at  all.  When  the  morbid  action  extends  to  both 
the  convexity  and  the  base,  there  is  a  combination  of  these  phenomena. 

Treatment. — To  afford  any  chance  of  a  favorable  result,  the  treat- 
ment should  be  energetic  from  the  first. 

General  bloodletting  may  be  practised  with  advantage  in  subjects  of 
good  constitution  and  of  the  middle  period  of  life.  As  many  as  twelve 
or  sixteen  ounces  may  be  taken  from  the  arm  if  the  pulse  is  hard,  the 
cephalalgia  intense,  or  the  delirium  furious.  Leeches  applied  behind 
the  ears  or  to  the  inside  of  the  nostrils  are  more  generally  of  advantage. 
The  same  may  be  said  of  cups  to  the  nucha. 

The  hair  should  be  cut  off  short,  and  ice  kept  constantly  applied  to 
the  scalp  during  the  first  and  second  stages.  It  is  better  than  the  cold 
douche,  for  the  reason  that  it  is  almost  impossible  to  continue  the  latter 
without  intermissions,  during  which  the  head  again  becomes  hot.  Com- 
presses wrung  out  of  cold  water  will  not  answer;  they  soon  get  heated, 
and  act  as  poultices.  Irrigation,  by  a  small  stream  of  ice-water  falling 
from  a  vessel  placed  above  the  head  of  the  patient,  is  a  useful  means  of 
applying  cold,  but  is  often  inconvenient. 

The  experiments  of  Dr.  Benham '  appear  to  show  that  cold  applied 
to  the  head  has  no  material  effect  in  reducing  the  intra-cranial  tempera* 
ture,  or  in  lessening  the  amount  of  blood  flowing  to  the  brain.  But  it 
must  be  borne  in  mind  that,  though  cold  applied  to  the  scalp  may  not 
reduce  the  normal  intra-cranial  temperature,  it  may  exercise  a  very 
different  influence  over  temperature  which  is  abnormally  high,  and  that 
his  experiments  with  Ludwig's  Strohm-uhr  were  but  three  in  number, 
lliut  the  cold  was  only  applied  for  thirty  minutes,  and  that  it  is  quite 
doubtful  if  the  Strohm-uhr  affords  the  best  means,  under  the  circum- 
stances, for  determining  the  quantity  of  blood  flowing  to  the  brain. 
In  actual  experience,  we  find  that  the  sedative  influence  of  cold  to  the 
head  is  .-is  well-established  a  fact  as  any  other  in  therapeutics,  and, 
though  it  may  EaU,  as  every  other  remedy  does  some  time  or  other,  to 
produce  its  expected  effect,  that  fact  should  be  no  reason  againsl  our 
employment  of  it  in  oases  in  which  it  appears  to  be  indicated.    In  i 

bra!  meningitis,  I  have  repeatedly  seen  the  violence  of  the  symp- 
toms mitigated  by  the  agent  in  question,  but,  in  order  to  obtain  this 

1  "On  the  Therapeutic  Value  of  Cold  to  the  Head,"  "Weet  Riding  Lunatic  Asylum 
Medical  Reports,11  vol.  It.,  1874,  p.  152. 


220  DISEASES   OF   THE   BRAIN. 

result,  it  should  be  kept  persistently  applied  in  the  forms  above  men* 
tioned. 

Purgatives  are  generally  advantageous  and  should  be  effective. 
Nothing  is  better  than  croton-oil,  although  calomel  and  podophyllin, 
grs.  x  with  grs.  ij,  make  a  good  combination  for  the  purpose. 

My  experience  has  satisfied  me  of  the  good  effects  of  mercurializa- 
tion.  I  have  administered  calomel  in  doses  of  a  grain  every  two  hours 
until  the  breath  became  fetid,  and  I  am  sure  the  effect  has  been  bene- 
ficial. 

The  iodide  of  potassium  is  well  spoken  of  by  Dr.  Flint,1  who  says  he 
has  witnessed  the  good  effects  of  the  drug  in  several  cases.  Dr.  F.  R. 
Lyman a  has  reported  two  cases  in  which  it  formed  a  prominent  feature 
of  the  treatment,  and  in  which  recovery  took  place. 

Within  late  years  in  the  few  cases  of  acute  cerebral  meningitis  that 
have  been  under  my  charge,  I  have  found  the  greatest  benefit  from  the 
bromide  of  potassium,  and  the  three  cases  that  recovered  were  instances 
in  which  it  was  administered  in  large  doses.  The  theory  upon  which  its 
employment  is  based  has  aheady  been  fully  considered  in  the  chapter  on 
cerebral  congestion.  It  should  be  administered  in  doses  of  at  least  thirty 
grains  three  or  four  times  a  day,  from  the  very  beginning  of  the  affec- 
tion to  the  end  of  the  second  stage  or  the  appearance  of  coma,  should 
this  symptom  supervene. 

The  head  should  be  kept  well  elevated,  the  chamber  cool,  and  well 
ventilated,  the  light  in  a  great  measure  excluded,  and  the  utmost  quiet 
enjoined. 

The  food,  without  being  stimulating,  should  be  nutritious.  Nothing 
is  superior  to  strong  beef-tea,  made  either  from  fresh  beef  or  from  some 
one  of  the  extracts  in  the  market. 

In  the  third  stage  the  treatment  should  be  almost  the  reverse  of  that 
indicated  as  proper  for  the  first  and  second  stages.  The  mercury,  iodide 
of  potassium,  bromide  of  potassium,  ice  to  the  head,  and  purgatives 
should  be  omitted,  and  attention  should  be  given  to  the  maintenance 
of  the  strength.  To  this  end  brandy,  whiskey,  or  other  alcoholic 
liquor,  should  be  administered  in  such  quantities  as  the  occasion  seems 
to  require.  It  often  happens  in  this  stage  that  the  delirium  and  exces- 
sive motility  return.  It  must  be  remembered  that  this  is  not  from  any 
renewal  of  morbid  processes  within  the  cranium,  but  is  entirely  due  to 
debility.  At  the  moment  of  writing  this,  a  young  lady  of  this  city  is 
under  my  charge  for  acute  cerebral  meningitis,  whom  I  did  not  see  till 
the  third  stage  was  well  advanced,  and  who  for  several  days  previously 
had  exhibited  a  return  of  the  delirium,  for  which  depletive  measures 
and  hydrate  of  chloral  had  been  employed.  The  free  administration  of 
brandy,  champagne,  and  beef-tea,  soon  dissipated  the  symptoms  of  re- 
lapse,  and  she  bids  fair  to  recover. 

1  Op.  cit.,  p.  601.  *  American  Medical  Times,  1862,  p.  334. 


CHRONIC   CEREBRAL   MENINGITIS.  031 

Blisters  may  be  used  in  this  stage  with  advantage.  They  aro 
best  applied  between  the  shoulders,  and  should  be  six  or  eight  inches 
square. 

In  the  rheumatic  form  of  the  disease  little  special  treatment  is  neces- 
sary. It  is,  perhaps,  advisable  to  endeavor,  by  means  of  blisters  or 
other  revulsives,  to  bring  back  the  disease  to  the  joints. 

In  the  acute  meningitis  of  the  aged,  active  depletive  treatment  is  not 
so  genera^y  admissible,  and  if  apparently  indicated  should  be  carried 
out  cautiously.  It  may  even  be  proper  to  treat  some  cases  with  stimu- 
lants from  the  very  first. 


CHAPTER  IX. 

CHRONIC  CEREBRAL  MENINGITIS. 

Although  it  is  scarcely  possible,  for  reasons  given  in  the  preceding 
chapter,  to  determine  from  the  symptoms  the  exact  seat  of  the  morbid 
process  in  an  attack  of  acute  cerebral  meningitis,  we  are  often  able,  in 
the  chronic  form  of  the  disease,  to  make  the  differential  diagnosis  with 
sufficient  accuracy.  I  shall  therefore  consider  the  affection  according  to 
its  location  under  the  heads  of  Chronic  Verticalar  Meningitis,  and 
Chronic  Basilar  Meningitis,  the  terms  being  applied  respectively  to 
chronic  inflammation  of  the  membranes  of  the  superior  surface  or  vertex 
of  the  brain,  and  chronic  inflammation  of  the  membranes  of  the  inferior 
surface  or  base  of  the  brain. 

I. — CHRONIC   VERTICALAR   MENINGITIS. 

This  disease  may  be  the  consequence  of  an  attack  of  acute  cerebral 
meningitis,  or  may  originate  without  being  thus  preceded.  The  latter 
is  the  usual  mode  of  development. 

Symptoms. — The  symptoms  of  chronic  verticalar  meningitis  are  in 
some  respects  similar  to  those  of  general  paralysis,  an  affection  which 
will  be  fully  described  as  one  of  the  forms  of  insanity;  and  tiny  also 
resemble  those  evolved  during  the  course  of  softening,  limited  to  the 
Clin  ex  porl  i<>n  of  the  brain. 

Among  the  physical  symptoms  headache  occupies  a  prominent  posi- 
tion and  is  usually  the  firsl  evidence  of  cerebral  disease  which  attracts 
the  attention  of  the  patient.  The  pain  is  generally  fell  in  the  fore- 
nead,  in  one  or  both  eyes,  or  at  the  vertex,  and  is  aggravated  by  men- 
tal ex<  rtion,  by  the  mere  aci  <>f  reading  or  fixing  the  attention,  by  mus- 
cular effort,  <>r  by  a  dependent  position  of  the  head.  It  is  nol  usually 
very  intense,  bu1  Is  characterized  l>y  persistency.  There  are  frequent 
attacks  of   vertigo.     Somnolency  is  generally  present,    and    there  are 


222  DISEASES   OF   THE   BRAIN. 

trembling,  defective  articulation,  weakness  of  the  limbs,  spasms  of  par- 
ticular muscles  or  groups  of  muscles,  paralysis  of  the  bladder  or  of  the 
sphincters  of  the  bladder  and  rectum,  producing  involuntary  discharges 
of  urine  and  faeces,  weakness  of  the  memory,  especially  as  regards 
words,  and  a  general  enfeeblement  of  the  mental  faculties.  Occa» 
sionally  there  are  epileptic  convulsions. 

Paralysis  of  the  whole  of  one  side  of  .the  body  may  ensue,  or  the 
loss  of  power  may  be  confined  to  a  single  limb,  or  to  a  growp  of  mus- 
cles. Anaesthesia  may  be  present,  either  general  or  local,  or  there  may 
be  neuralgic  pains  in  various  parts  of  the  body,  sometimes  of  a  very 
persistent  character.  The  ocular  muscles  are  not  often  implicated, 
either  by  spasm  or  paralysis;  and  the  special  senses,  except  that  of  gen- 
eral sensibility,  are  not  usually  impaired.  Convulsions  of  an  epilepti- 
form character  are  not  uncommon. 

Unless  the  cortical  substance  of  the  brain  participates  in  the  morbid 
action  there  is  not  ordinarily  marked  mental  aberration,  although  there 
is  a  general  failure  of  mental  power.  Under  the  name  of  "  general 
paralysis,"1  and  subsequently  of  "chronic,  diffused  periencephalitis,3" 
Calmeil  described  a  disease  which  is  now  well  known,  and  in  which  the 
cortical  portion  of  the  upper  part  of  the  cerebrum  is  in  a  condition  of 
chronic  inflammation,  the  membranes  of  the  region  being  also  involved. 
But  the  peculiarities  of  general  paralysis  are  so  well  marked  as  to  ne- 
cessitate separate  description. 

The  ophthalmoscope  does  not,  in  this  affection,  generally  reveal  any 
very  notable  changes  in  the  fundus  of  the  eyes.  Occasionally,  where 
there  is  reason  to  suspect  its  existence,  there  is  ischaemia  papillae,  and 
still  more  rarely  neuro-retinitis.  As  Dr.  Allbutt 3  has  remarked,  the 
optic  nerves  in  drunkards  affected  with  meningitis  of  the  convex  surface 
of  the  brain  "  are  often  degenerated,  and  the  vessels  injected,  but  these 
effects  do  not  seem  to  be  due  to  any  meningitic  process."  When, 
however,  the  meningitis  is  courplicated  with  inflammation  of  the  cortical 
substance  of  the  brain,  neuro-retinitis  is  a  frequent  accompaniment. 

The  general  health  participates  more  or  less  in  the  disturbance. 
The  stomach  is  irritable,  and  vomiting  is  frequent,  the  bowels  are 
usually  obstinately  constipated,  and  the  urine  is  scanty  and  high- 
colored,  often  containing  oxalate  of  lime  and  an  excessive  amount  of 
uric  acid. 

As  the  disease  advances,  the  mental  and  physical  symptoms  become 
more  and  more  pronounced.  The  mind  is  weaker,  delirium  is  not  in- 
frequent, convulsions  occur  oftener,  and  the  paralysis  extends  and  be- 
somes  more  profound.     Blindness  from  pressure  upon  the  optic  nerves 

1  "De  la  paralysde  consideree  chez  les  alienes,"  Paris,  1826. 
■  "Trait6  des  maladies  inilammatoires  du  cerveau,"  Paris,  1859, 
8  "  On  the  Use  of  the  Ophthalmoscope  in  Diseases  of  the  Nervous  System,"  etc.,  Lon- 
don and  New  York,  1871,  p.  108. 


CHRONIC   CEREBRAL   MENINGITIS.  223 

may  result.  A  state  of  continued  coma  now  supervenes,  during  which 
the  patient  expires,  or  death  takes  place  in  convulsions. 

The  duration  of  the  disease  varies  from  two  or  three  months  to  one 
or  more  years. 

An  interesting  case  of  meningitis  affecting  the  membranes  at  the 
convexity  of  the  brain,  is  that  of  the  eminent  Swiss  savant  De  Saussure, 
related  by  Dr.  Odier.1 

For  many  years  M.  de  Saussure  had  been  accustomed  to  great  bodily 
fatigue,  and  to  various  degrees  of  atmospheric  pressure,  encountered 
in  the  many  ascents  of  mountains  he  had  made.  He  had  been  subject 
to  an  aggravated  form  of  dyspepsia,  and  to  repeated  large  losses  of 
blood  from  haemorrhoids. 

At  the  end  of  the  year  1793,  after  having  lost  his  fortune,  and  ex- 
perienced a  good  deal  of  mental  disturbance  from  the  unsettled  condi- 
tion of  the  national  affairs,  he  was  suddenly  seized  with  vertigo,  which 
was  followed  by  distinct  sense  of  numbness  in  the  left  arm  and  cheek. 
The  vertigo  did  not  last  long,  but  nothing  could  relieve  the  feeling  of 
numbness  or  torpor.  Blisters,  purgatives,  tonics,  and  anti-spasmodics, 
were  employed  in  vain.  The  affection  of  the  arm  seemed  to  be  seated  en- 
tirely in  the  sentient  nerves,  for  the  patient  retained  his  strength,  could 
perform  all  kinds  of  movements,  but  could  not  distinguish  easily  what 
he  was  touching.  It  seemed  to  him  as  if  sand  were  interposed  between 
his  fingers  and  the  bodies  with  which  he  brought  them  in  contact. 
The  sensation  experienced  was  rather  painful  than  otherwise,  so  that 
he  was  indisposed  to  use  his  hands  unless  they  were  protected  with 
gloves.  A  similar  feeling  existed  in  the  cheek  and  mouth  on  the  same 
side,  which,  on  passing  his  hand  over  his  face,  formed,  in  the  most  un- 
pleasant ma  niier,  a  well-marked  line  of  demarkation  between  the  right 
and  left  side.  In  other  respects  he  was  well;  his  general  health  was 
not  impaired,  and  he  retained  for  a  long  time  his  presence  of  mind  and 
the  fullness  of  his  intellectual  powers.  Many  months  were  passed  in 
this  state,  during  which  a  great  variety  of  remedies  were  tried,  such  as 
cold  and  warm  bathing,  electricity,  arnica,  valerian,  blisters,  embroca- 
tions, artificial  and  natural  thermal  waters,  change  of  regimen,  travel- 
ing, etc.,  but  all  in  vain.  The  disease  became  worse  and  worse;  always, 
however,  by  starts,  the  a1  lacks  being  more  or  less  violent  and  oomplete, 
One  of  the  mosl  violenl  was  occasioned  Buddenly  at  Bourbon,  by  a 
Bhower-batfa  employed  t<">  warm.  The  attack  produoed  by  it  was  so 
oomplete  thai  the  whole  of  the  left  side,  from  the  leg  to  the  tongue,  was 
affected.  His  artioulation  became  by  degrees  indistinct  and  unintelli- 
gible. His  legs,  especially  the  left,  became  weaker,  and  bis  gail  was 
stage;'1  ring,  and  he  found  it  almost  impossible  to  maintain  his  equilib- 
rium and  to  direct   his  steps  as  he  wanted.     He  experienced  peculiar 

1  "  An  Account  of  the  uloesi  and  Death  of  II.  B.  '!»•  Saussure,  late  Professor  of  Pht 
i,"  BMnburyh  Mediealmd  SurgioaiJowmqh  vol,  ii.,  1806,  p.  898. 


224  DISEASES   OF  THE   BRAIN. 

difficulty  in  passing  through  doors,  even  when  they  were  wide  open, 
and  no  descent  or  ascent  to  make.  As  he  approached  a  door  he  bal- 
anced himself,  and  quickened  his  motion  as  if  he  had  to  make  a  dan- 
gerous leap  or  a  bad  step  to  get  over;  when  it  was  done  he  recovered 
Ills  equilibrium,  crossed  the  room,  but  had  the  same  trouble  in  order 
to  get  to  another  apartment.  Day  by  day  the  disease  advanced;  the 
intellectual  faculties  became  perceptibly  weaker;  incontinence  of  urine 
supervened.  The  evening  before  his  death  he  seemed  to  enjoy  his  sup- 
per, but  was  restless  during  the  night;  toward  morning  his  head  leaned 
to  one  side,  he  breathed  with  more  difficulty  than  usual,  and  expired 
without  agony. 

On  opening  the  body  thirty-two  hours  after  death,  the  dura  mater 
was  found  adherent  to  the  cranium,  particularly  along  the  longitudinal 
sinus,  but  that  deviation  from  the  natural  condition  was  not  considered 
of  importance,  it  being  often  met  with  unassociated  with  intra-cranial 
disease.  Between  the  pia  mater  and  the  arachnoid  there  was  found 
a  considerable  effusion  of  a  bluish  gelatinous  substance.  In  various 
places  there  were  circular  spots  of  a  gray  yellowish  color  about  two  or 
three  lines  in  diameter.  These  seemed  as  though  they  penetrated  into 
the  membranes,  though  susceptible  of  being  detached  from  them  like 
small  separate  spheres  surrounded  by  a  little  circular  margin  of  a  dark- 
red  color.  At  first  sight  these  spots  were  taken  for  hydatids,  but  closer 
examination  showed  that  the  red  margin  was  a  blood-vessel  connected 
with  other  vessels,  and  convoluted  in  the  form  of  circles.  There  were 
no  separate  pouches  or  solutions  of  continuity  in  the  membranes,  only 
they  were  more  transparent  in  those  places  than  in  others.  The  seros- 
ity  underneath  communicated  freely  with  that  which  was  diffused  over 
all  the  surface  of  the  brain,  both  having  the  same  color  and  qualities. 
On  opening  the  membranes  the  serous  effusion  ran  off  like  water.  The 
effusion  existed  not  only  over  the  surface  of  the  cerebrum,  but  also 
over  that  of  the  cerebellum.  The  ventricles  also  were  distended  with  a 
similar  fluid.  The  examination  of  the  brain  presented  nothing  more  of 
importance  except  that  it  was  flattened  on  the  surface  and  deeply 
furrowed  by  arteries.  The  total  duration  of  the  disease  was  five  years, 
although  the  beginning  may  have  been  anterior  to  the  apparent  time 
of  origination,  as  it  was  stated  that  Prof,  de  Saussure,  long  before  his 
death,  had  often  mistaken  one  word  for  another  in  conversation,  and 
was  so  unconscious  of  his  error  as  to  get  angry  when  not  understood. 

Dr.  Odier  attributed  the  death  of  the  patient  to  the  effusion  of  a 
large  quantity  of  serum  into  the  ventricles  and  between  the  membranes 
of  the  brain.  That  this  effusion  resulted  from  chronic  meningitis  is 
scarcely  a  matter  of  doubt. 

Gintrac1  cites  the  following  case:  "  A  young  man  sixteen  years  old, 

1  Op.  cit.,  tome  ii.,  p.  626.  Quoted  from  Bruce,  "  Medico-Chirurgical  Transactions," 
London,  1818,  vol.  ix.,  p.  280. 


CHRONIC   CEREBRAL   MENINGITIS.  225 

very  tall,  was  attacked  in  December  with  feebleness  of  sight,  strabismus, 
dilatation  of  the  pupils,  diplopia,  and  headache  ;  pulse  natural,  consti- 
pation, epistaxis;  convulsions,  with  foaming  at  the  mouth;  coma  and 
stertor,  which  were  relieved  by  bleeding  from  the  temporal  artery,  but 
which  returned  twenty-four  hours  later.  Delirium  supervened,  charac- 
terized by  violent  language,  and  attempts  to  strike  and  bite  those 
around  him  ;  pulse  frequent.  The  wound  in  the  artery  being  reopened, 
repeated  losses  of  blood  occurred,  and  the  convulsions  returned.  Sight 
weakened,  ideas  confused,  appetite  voracious,  general  debility,  but 
power  of  walking,  of  comprehension,  and  of  speech,  remained.  Then 
somnolency,  attended  with  spasmodic  movements  of  the  muscles,  es- 
pecially of  those  of  the  face,  appeared.  The  face  was  red  and  swollen, 
especially  on  the  left  side.  Death  occurred  in  violent  convulsions  two 
months  after  the  beginning  of  the  disease. 

"  The  cerebral  blood-vessels  were  found  to  be  very  much  injected. 
On  the  left  anterior  lobe  there  was  a  slight  effusion  of  blood;  a  little 
serum  in  the  ventricles;  substance  of  the  brain  firm;  numerous  puru- 
lent spots  along  the  line  of  superior  longitudinal  sinus." 

M.  Casimir  Broussais '  submitted  to  the  Academie  de  Medecine  a 
pathological  specimen  with  the  history,  of  which  I  give  the  main 
points: 

Lozeray,  a  sapeur  pompier,  twenty-two  years  old,  entered  the  hos- 
pital Val-de-Grace  August  1,  1840.  Six  days  previously  he  had  been 
attacked  with  headache  and  slight  fever.  The  evening  of  his  entrance 
he  was  bled.  He  improved,  the  pain  disappeared,  and  his  appetite  re- 
turned. On  the  7th  of  August  he  had  a  relapse;  hardly  answered  the 
questions  addressed  to  him;  remained  motionless  in  bed;  was  entirely 
paralyzed  in  the  right  arm  and  leg;  was  again  bled.  The  next  day, 
being  comatose,  venesection  was  again  practised,  and  twenty  leeches 
were  applied  to  the  temples.  On  the  9th  the  paralysis  had  disappeared, 
but,  as  he  was  still  comatose,  another  venesection  was  performed,  and 
fifteen  leeches  were  applied  to  the  neck  over  the  jugular  vein.  On  the 
10th  was  bled  again;  still  comatose,  and  the  right  arm  contracted.  ( hi 
the  12th  had  epileptio  paroxysms,  during  which  it  was  remarked  that 
one  side  was  more  convulsed  than  the  other;  coma  profound;  eighteen 
leeches  to  the  jugulars;  14th,  15th,  and  16th,  Bame  symptoms;  an 
enormous  bed-sore  on  the  Bacrum.  On  the  18th  coma  less  complete; 
epileptic  convulsions,  especially  in  the  night.  From  this  time  he  con- 
tinued to  Improve  till  the  28th,  when  <  ain  supervened,  and  on 
the  89th  he  died. 

On  posl  mortem  examination  the  dura  mater  was  found  healthy. 
On  being  incised,  a  quantity  of  sero-purulent  fluid  esoaped.     The  mem- 
brane was  adherent   to  the  brain,  principally  on  the  convex  Buri 
and  especially  on  the  right  side,  so  that  it  was  impossible  to  detach  ii 

1  "Bulletin  ilu  L'ftoademk  royale  de  medeoine,*1  tome  v.,  1840,  p.  504. 
10 


226  DISEASES   OF   THE  BRAIN. 

entirely  -without  rupture.  On  the  right  side  it  formed  a  sac  extending 
over  about  three-fourths  of  the  convex  surface,  containing  from  two 
hundred  to  two  hundred  and  fifty  grammes  of  a  greenish-white  sero- 
purulent  fluid.  Another  sac,  containing  from  fifty  to  sixty  grammes  of 
this  fluid,  existed  on  the  left  side. 

The  dura  mater  was  removed,  and  it  was  ascertained  that  this  fluid 
came  from  the  cavity  of  the  arachnoid  and  from  the  meshes  of  the  pia 
mater. 

In  the  case  of  a  gentleman  under  my  charge  there  was  intense  head- 
ache as  the  first  prominent  symptom,  followed  by  epileptiform  convul- 
sions, and  varying  degrees  of  paralysis,  both  of  motion  and  of  sensa- 
tion on  one  side  of  the  body  and  again  on  the  other.  When  I  first 
saw  him  the  optic  nerves  had  been  so  injured  by  the  pressure  from 
effused  fluid  as  to  cause  complete  blindness.  Light  could  not  be  dis- 
tinguished from  darkness.  The  ophthalmoscope  showed  extreme  atro- 
phy of  both  nerves,  probably  either  the  result  of  pressure  or  the  conse- 
quence of  neuritis  from  extension  of  the  cerebral  disease.  The  accumu- 
lation of  fluid  was  so  great  as  to  force  open  the  bi-parietal,  the  fronto- 
parietal, and  the  occipito-parietal  sutures.  Under  treatment  the  excess 
of  fluid  disappeared,  the  pain  ceased,  and  he  acquired  the  power  of 
vision  to  such  an  extent  as  to  enable  him  to  tell  light  from  darkness, 
and  even  to  make  out  the  figures  on  a  bright  carpet.  He  died,  how- 
ever, about  six  months  after  leaving  New  York,  of  cancer  of  the  stom- 
ach. There  was  no  post-mortem  examination  of  the  brain,  or  none  that 
was  reported  to  me,  but  I  am  strongly  of  the  opinion  that  the  disease 
was  chronic  meningitis  of  the  convexity  of  the  brain,  resulting  in  a  large 
effusion  of  serum. 

Causes. — The  etiology  of  chronic  cerebral  verticalar  meningitis  is 
often  difficult  to  make  out.  Sometimes,  however,  the  affection  is  the 
result  of  an  acute  attack.  At  times  it  clearly  originates  from  blows  or 
falls  upon  the  head,  and  again  it  is  caused  by  exposure  to  the  heat  of 
the  sun  or  to  artificial  heat.  There  is  certainly  a  form  of  chronic  in- 
flammation of  the  membranes  of  the  convex  surface  of  the  brain,  which 
is  due  to  the  extreme  heat  of  the  sun,  not  necessarily  to  the  action  of 
the  direct  rays,  and  which  is  characterized  by  the  symptoms  I  have  speci- 
fied. I  see  some  cases  of  this  every  year  in  New  York,  and  have  wit- 
nessed several  similar  instances  in  cooks  and  others  whose  occupations 
necessitated  the  exposure  of  the  vertex  to  intense  or  long-continued 
heat. 

The  affection  in  question  may  also  be  induced  by  mental  influence, 
especially  anxiety  and  other  forms  of  emotional  disturbance;  and  this 
category  of  causes  is  probably  the  most  influential  of  all  others,  with 
the  single  exception  of  excessive  alcoholic  potations.  So  far  as  our 
knowledge  extends,  this  last  is  the  most  common  factor  in  the  causation 
of  chronic  verticalar  meningitis. 


CHRONIC   CEREBRAL  MENINGITIS.  227 

Syphilis  is  another  influential  cause,  though  generally,  as  we  shall 
see  hereafter,  it  acts  preferably  upon  the  basilar  portion  of  the  mem- 
branes. 

It  is  probably  sometimes  induced  by  rheumatism  and  gout,  and  cer- 
tainly occasionally  by  tubercular  deposit,  but  when  arising  from  this 
last-named  cause  it  is  not  to  be  confounded  with  tubercular  cerebral 
meningitis,  the  seat  of  which  is  in  the  membranes  at  the  base  of  the 
brain,  and  which  is  otherwise  differently  characterized. 

Diagnosis. — This  is  often  impossible  to  be  made  out,  with  even  a 
moderate  degree  of  exactness,  and  is  always  more  or  less  difficult.  The 
affection  may  be  confounded  with  inflammation  and  softening  of  the 
cortical  substance  of  the  cerebrum,  and  the  most  careful  study  will  in 
many  cases  fail  in  discriminating  between  them.  The  difficulty  is  fre- 
quently heightened  by  the  fact  that  the  two  diseases  coexist.  But  we 
are  much  assisted  by  a  thorough  investigation,  not  only  of  the  symp- 
toms, but  of  the  causes.  For  instance,  a  category  of  phenomena  such 
as  has  been  given,  resulting  from  exposure  to  intense  heat,  is  generally 
due  to  chronic  inflammation  of  the  membranes  of  the  superior  surface 
of  the  brain,  and  the  same  may  be  said  of  syphilis.  When,  however, 
the  symptoms  follow  undue  mental  exertion  or  emotional  excitement, 
the  distinction  is  more  difficult,  and  indeed  in  such  cases  the  substance 
of  the  cortex  is  usually  also  involved. 

In  general,  the  pain  which  is  so  prominent  a  feature  in  inflammation 
of  the  membranes,  is  not  so  marked  an  accompaniment  of  softening, 
while  in  the  latter  the  mental  disturbance  is  greater  than  when  the 
morbid  process  is  confined  to  the  meninges.  From  inflammation  of  the 
membranes  at  the  base  of  the  brain,  the  affection  under  consideration 
is  distinguished  by  the  almost  constant  absence  of  ocular  paralysis, 
and  by  the  fact  that  the  seat  of  the  pain  is  different,  and  that  the  mind 
is  more  decidedly  involved. 

The  ophthalmoscopic  appearances  will  suffice  for  the  diagnosis  from 
aniemia  or  hypenemia  of  the  brain,  or  frcm  megrim  or  neuralgia,  even 
if  the  other  points  in  the  clinical  history  are  not  sufficient. 

Prognosis. — The  prognosis  in  cases  of  chronic  inflammation  of  the 
meninges  of  the  convex  surface  of  the  brain  is  decidedly  unfavorable, 
unless  a  syphilitic  origin  can  be  made  out,  in  which  event  the  prospect 
of  recovery  is  good.  But  even  in  such  a  case  the  disease  must  be  early 
subjected  to  proper  treatment,  for  the  disposition  to  extend  to  the  sub- 
stance of  tin;  brain  vrhiob  the  affection  so  often  manifests,  and  the  tact 
that  inw  formations  arc  liable  to  be  produced  and  to  exert  an  abnormal 
influence  upon  the  nerve-tissue,  very  greatly  increase  the  probability  of 
an  unfavorable  result. 

Nevertheless,  I  am  s;il  islieil  that  even  where  there  is  no  suspicion  "f 
syphilis,  ohronic  rerticalax  meningitis  La  Bometimea  successfully  com- 
bated.    This  point  will  1>«  further  considered  under  the  head  of  treat- 


228  DISEASES   OF   THE   BRAIN. 

ment.  In  the  mean  time  I  quote  the  following  case  from  Dr.  E.  L. 
Fox,1  of  Bristol,  England,  in  which  a  post-mortem  examination  gave 
evidence  of  the  previous  existence  of  the  disease  in  question.  It  is 
possible  there  was  a  syphilitic  taint  in  this  case,  though  nothing  is  said 
on  the  subject: 

"The  patient,  a  young  man,  had  died  of  an  attack  of  haemorrhage, 
from  rupture  of  the  right  middle  meningeal  artery,  but  the  dura  mater, 
all  over  the  convex  surface  of  the  hemispheres,  was  somewhat  adherent 
to  the  subjacent  arachnoid,  while  the  arachnoid  was  thickened  and  yel- 
low all  over.  This  patient  had  been  under  Mr.  Parker's  care  a  year  be- 
fore, with  great  pain  all  over  the  upper  part  of  the  head,  without  any 
delirium,  and  had  been  treated,  with  entire  success,  with  iodide  of  po- 
tassium. In  this  case,  therefore,  arachnitis  had  existed  without  any 
lesion  of  the  cerebral  matter  itself,  and  without  delirium." 

Morbid  Anatomy  and  Pathology. — The  essential  features  in  the  mor- 
bid anatomy  of  chronic  cerebral  verticalar  meningitis  are  hyperemia 
of  the  vessels  and  a  new  formation  of  connective  tissue  by  which  the 
membranes  adhere  to  each  other  and  to  the  brain,  and  by  which  they 
are  rendered  opaque,  and  thicker  than  normal. 

In  addition,  there  may  be  deposits  of  exudation  on  the  convexity 
of  the  brain  which,  though  intimately  connected  with  the  alterations  of 
the  membranes,  are  yet  distinct  from  them.  These,  as  characterized 
by  Gintrac,3  may  consist  of  serum  effused  under  the  arachnoid,  of  a 
thick,  gelatiniform,  discolored  fluid  in  the  same  situation,  of  pus  con- 
tained either  in  the  cavity  of  the  arachnoid  or  infiltrated  into  the 
meshes  of  the  pia  mater,  of  false  membranes  formed  in  the  cavity  of 
the  arachnoid,  non-adherent,  adherent  to  one  or  other  layer  of  this 
membrane,  or  double,  composed  of  an  external  layer  of  the  arachnoid, 
and  an  internal,  adherent  to  the  visceral  lamina,  thus  constituting  cysts, 
which  may  contain  blood-serum  or  other  matter. 

Of  one  hundred  and  sixty-seven  cases  of  meningitis  of  the  convexity 
of  the  brain  collected  by  Gintrac — in  which,  however,  the  distinction 
between  the  acute  and  chronic  forms  of  the  disease  is  not  drawn — the 
relative  proportion  of  morbid  conditions  was  as  follows : 

Injection,  opacity,  or  thickening  of  the  membranes 9 

Serous  exudation S3 

Gelatiniform  exudation 14 

Pus 30 

False  membranes 81 

Total 167 

Fox8  has  very  clearly  shown  that  tubercle  may  be  associated  with 

>  "  Clinical  Observations  on  Acute  Tubercle,"  "  St.  George's  Hospital  Reports,"  Lon- 
don, 18G9,  vol.  iv.,  p.  61. 

2  Op.  cit.y  tome  ii.,  p.  604.  8  Op.  et  he.  cit. 


CHRONIC   CEREBRAL   MENINGITIS.  229 

chronic  meningitis  of  the  convexity  of  the  brain.  The  following  case, 
which  I  cite  from  him,  is  so  interesting  in  several  respects,  that  I  quote 
it  in  full,  so  far  as  the  description  relates  to  the  brain: 

"  Case  XXII. — Henry  B.,  aged  twenty-four,  tailor;  ill  one  month 
with  pain  in  the  forehead;  no  cough.  When  first  examined  in  recum- 
bent position,  a  sharp,  blowing,  systolic  murmur  was  heard  at  the  base 
of  the  heart,  traveling  up  toward  the  left  shoulder;  a  little  later  he  had 
sickness,  then  intense  pain,  chiefly  at  back  of  head.  Head  jerks  back- 
ward at  every  beat  of  the  heart;  much  cerebral  throbbing.  Temporary 
relief  from  blisters,  cold  to  the  head,  and  purgatives;  but  eventually 
more  sickness,  diplopia,  which,  however,  was  intermittent,  and  in- 
creased headache.  Then  almost  total  freedom  from  pain,  and  all  mor- 
bid symptoms,  and  he  was  able  to  be  out;  but  he  died  suddenly  in  a 
fit,  three  months  from  the  commencement  of  his  illness.  No  bronzing 
of  skin. 

"Post-mortem  Examination. — Dura  mater  externally  seemed  healthy ; 
internally  it  was  firmly  adherent  to  the  subjacent  tissues  at  the  spots 
below  mentioned;  veins  of  convex  surface  of  hemispheres  tinged  with 
blood.  On  left  hemisphere,  about  middle  of  brain,  was  a  spot  of  tuber- 
culous matter  the  size  of  a  filbert,  which  seemed  to  be  immediately  con- 
nected with  the  vessels  of  the  pia  mater,  to  have  become  adherent  on 
the  one  side  to  the  dura  mater,  and  on  the  other  to  have  extended 
through  the  gray  matter  for  a  few  lines  into  the  white.  The  two  lat- 
eral and  third  ventricles  much  distended  with  clear  fluid,  containing  a 
few  small,  white  flakes.  Foramen  of  Monro  enlarged  sufficiently  to 
contain  a  small  nut.  Walls  of  ventricles  very  soft;  optic  thalami 
tolerably  firm.  Corpora  striata  excessively  pulpy;  pons  and  medulla 
oblongata  everywhere  rather  soft.  On  anterior  lobe  of  right  hemi- 
sphere, just  on  the  lateral  surface,  was  another  tuberculous  spot  the  size 
of  a  nut.  On  the  external-  surface  of  the  cerebellum,  close  to  the  floc- 
culus on  left  si<l'',  though  not  involving  it,  was  a  large  mass  of  tubercule, 
dipping  into  the  structure  of  the  cerebellum,  and  uniting  this  organ  to 
f!i<  posterior  lobe  of  the  left  cerebral  hemisphere.  More  than  three- 
quarters  of  ihe  left  half  of  the  cerebellum  were  occupied  by  large  ves- 
sels of  the  same  growth,  which  apparently  had  grown  separately,  and 
by  gradual  Increase  of  size  had  at  length  become  one  mass.  The  dura 
mater  was  adherent  over  a  great  part  of  this  side  of  the  cerebellum, 
and  the  cerebellar  structure  that  remained  was  almost  diffluent.  The 
other  side  of  the  <■•  rebellum  was  also  much  softened." 

This  case  is  remarkable,  not  only  for  the  intermittence  in  the  symp- 
toms, to  which  1  )r.  I'<>x  calls  attention,  but  also  lor  the  lightness  of  the 
phenomena  when  compared  with  the  severity  and  extent  of  the  lesi 
Such  remissions  in  the  manifestations  of  cerebral  disease  as  were  ex- 
hibited in  this  ease,  though  uol  unusual,  an-,  in  the  present  state  of  our 
knowledge,  Dot  easy  of  explanation.     For  it  is  rery  evident  that  there 


230  DISEASES   OF   THE  BRAIN. 

was  a  steady  advance  of  the  morbid  processes  up  to  the  very  instant 
of  death,  and  yet  the  patient  died  suddenly,  having  up  to  that  time 
passed  through  a  period  of  almost  entire  freedom  from  pain  and  all 
morbid  symptoms. 

I  am  tempted  also  to  cite  the  next  case  from  Dr.  Fox's  memoir,  on 
account  of  a  like  slightness  of  symptoms  existing  in  connection  with 
extensive  cerebral  lesions. 

Case  XXIII. — Catharine  S.,  aged  thirty-one,  servant;  single;  pale, 
lean  woman;  has  had  vertigo  and  pain  in  back  of  the  head  for  five  weeks; 
no  sickness,  no  rigors,  pulse  now  very  feeble  and  hurried.  Tongue 
coated;  skin  hot;  no  sickness  until  eight  days  after  admission,  and  she 
coughed  first  on  the  ninth  day.  Became  delirious,  but  was  always  capable 
of  answering  questions  reasonably,  and  the  chief  symptom  was  a  gradu- 
ally increasing  weakness  of  pulse.  Sank  quietly  out  of  life,  without 
coma,  on  the  twenty-second  day  after  admission,  having  had  no  convul- 
sions throughout,  and  no  cerebral  respiration  until  the  last  day  of  life. 

"  Post-mortem  Examination. — Cranium  :  Arachnoid,  and  subjacent 
tissues  on  convex  surface  of  the  hemispheres,  contained  much  clear 
fluid,  but  were  otherwise  natural.  Between  the  cerebral  hemispheres 
and  the  longitudinal  fissure  were  a  number  of  small,  miliary  tubercles, 
and  at  the  lower  part  of  this  fissure  the  opposed  hemispheres  were  ad- 
herent to  each  other  by  means  of  a  mass  of  tuberculous  matter  the  size 
of  a  nut.  A  small  portion  of  similar  matter  was  found  at  the  upper 
part  of  the  cerebellum,  connected  with  the  arachnoid.  The  venous 
tissue  around  these  tuberculous  masses  was  very  much  softened  and 
ecchymosed.  Two  similar  masses  were  also  found  in  inner  wall  of  pos- 
terior horn  of  each  lateral  ventricle.  Ventricles  full  of  turbid  fluid,  and 
their  walls  softened." 

It  sometimes  happens  that  chronic  inflammation  of  the  membranes 
of  the  vertex  of  the  brain  exists  without  the  occurrence  of  notable 
symptoms.  Several  such  cases  have  come  under  my  own  observation  in 
which,  after  death,  the  membranes  were  found  thickened,  opaque,  and 
adherent,  and  in  which,  during  life,  no  complaint  of  cerebral  disturb- 
ance had  been  made.  It  is  probable,  however,  that  symptoms  of  such 
disturbance  have  existed,  but  have  not  been  mentioned  by  the  patient. 

Treatment. — The  treatment  depends  to  some  extent  upon  the  cause, 
although  the  general  management  of  the  disease  is  not  subject  to  any 
very  essential  variation,  however  it  may  originate.  Thus  the  iodide  of 
potassium  is  in  all  cases  the  agent  most  to  be  relied  upon.  When  the 
affection  is  due  to  syphilis,  or  has  followed  syphilitic  infection,  the  iodide 
must  be  administered  with  much  more  persistency  and  in  larger  doses 
than  when  not  so  associated.  In  all  cases,  however,  it  must  be  given  in 
what  may  be  called  large  doses,  and  must  be  continued  for  several 
months.  In  uncomplicated  cases  the  quantity  administered  may  be  at 
first  ten  grains  three  times  a  day,  gradually  increased  to  thirty  grains 


CHRONIC   CEREBRAL   MENINGITIS.  231 

for  each  dose;  but  in  syphilitic  cases  the  doses  wall  often  have  to  be 
carried  to  eighty  or  even  a  hundred  grains  thrice  daily.  The  iodide  of 
potassium  should,  in  my  opinion,  always  be  given  in  gradually- increas- 
ing doses.  This  is  best  effected  by  using  a  saturated  solution  of  the 
medicine  in  water,  each  minim  of  which  contains  about  a  grain  of  the 
salt.  For  the  first  day  ten  minims  may  be  given  three  times,  for  the 
second  day  eleven,  and  so  on  till  the  maximum  dose,  which  it  may  be 
deemed  proper  to  administer,  is  reached.  I  have  several  times  had 
cases  under  my  charge  in  which  no  sign  of  amelioration  occurred  till 
doses  of  from  eighty  to  one  hundred  grains  thrice  daily  were  used. 

Some  one  of  the  bromides  may  be  very  advantageously  given  in 
addition  to  the  iodide  of  potassium.  The  bromide  of  calcium  is  to  be 
preferred  in  almost  all  cases.  It  acts  more  rapidly  than  the  others,  and, 
notwithstanding  the  recent  opinion  of  a  German  physician,  more  effect- 
ually. The  doses  should  be  about  fifteen  grains  daily,  and  each  dose 
may  be  given  with  that  of  the  iodide  of  potassium.  It  must  not  be 
forgotten  that  these  medicines  must,  when  taken,  be  administered 
in  a  large  quantity  of  water  (half  a  tumbler,  for  instance).  They  act 
better,  and  are  less  liable  to  irritate  the  stomach,  when  they  are  well 
diluted. 

Under  the  combined  action  of  the  bromide  and  iodide,  the  relief 
from  all  symptoms  of  intra-cranial  disease  is  often  very  striking.  This 
is  especially  apt  to  be  the  case  when  syphilis  is  at  the  bottom  of  the 
morbid  process. 

Relative  to  the  propriety  of  administering  mercury  in  chronic  cere- 
bral verticalar  meningitis,  much  depends  upon  the  nature  and  duration 
of  the  disease.  In  non-syphilitic  cases  it  is  not  indicated,  nor  in  those 
instances  in  which  the  syphilitic  infection  is  remote,  but,  where  the  pri- 
mary disease  is  recent,  mercury  is  of  service  as  an  addition  to  the  other 
measures.  It  may  be  given  in  the  form  of  the  biniodide,  or  the  bi- 
chloride, in  doses  of  the  sixteenth  of  a  grain  two  or  three  times  a  day. 

For  the  relief  of  the  pain,  which  is  sometimes  very  severe,  a  pill  con- 
taining  half  a  grain  of  codeia  maybe  prescribed  with  advantage,  as 
often  as  required. 

In  regard  to  local  medication,  I  am  inclined,  from  more  recent  ex- 
periences, to  believe  that  blisters  applied  to  the  nape  of  the  neck  are 
occasionally  beneficial.  As  a  rulo,  however,  I  do  not  employ  them,  or 
any  other  revulsive,  or  counter-irrit  ant  means. 

The  patient  should  bo  instructed  not  to  over-exert  the  mind,  to  avoid 
all  causes  of  excitement,  mental  or  physical,  and  live  in  striol  accord- 
ance with  hygienic  principles. 

CHRONIC    BABE  LB    minim. 1 1  is. 

Chronii'  basilar  meningitis  is  very  seldom  the  oonsequenoe  of  an 

acute  attack,   probably  mainly  for   the  reason  that   acute   inllammation 


232  DISEASES  OF  THE  BRAIN. 

of  the  membranes  at  the  base  of  the  brain  is  almost  invariably  a  fatal 
affection. 

Symptoms. — Although  there  is  genei'ally  pain  from  the  very  incep- 
tion of  chronic  basilar  meningitis,  the  first  very  decided  symptom  is 
sometimes  an  epileptiform  paroxysm.  Or  there  may  be  convulsive 
movements  of  a  limb,  a  group  of  muscles,  or  a  single  muscle,  unat- 
tended with  loss  of  consciousness. 

Again,  there  may  be  tonic  spasms  of  the  muscles  of  one  or  more  of 
the  extremities,  especially  of  the  arms ;  or  the  muscles  of  the  neck  may 
be  similarly  affected,  causing  the  head  to  be  fixed  in  an  abnormal  posi- 
tion.    The  individual  muscles  of  the  face  are  not  usually  involved. 

But  ordinarily  the  primary  serious  indication  of  intra-cranial  dis- 
ease is  paralysis.  This  may  appear  in  the  head,  arm,  the  hand,  or  a 
single  finger;  or  one  side  of  the  tongue  may  be  affected,  giving  rise  to 
defective  articulation,  and  to  a  deviation  toward  the  paralyzed  side 
when  the  tongue  is  protruded,  or  the  muscles  supplied  by  the  seventh 
nerve  may  be  affected  and  facial  paralysis  be  produced.  In  the  great  ma- 
jority of  cases,  however,  some  one  of  the  motor  nerves  of  the  eyeball  is 
first  involved  in  the  morbid  process,  and  this  is  generally  the  third  nerve 
of  one  side,  resulting  in  ptosis,  external  strabismus,  and  diplopia,  dila- 
tation of  the  pupil,  and  defective  power  of  accommodation. 

Sometimes  the  implication  of  the  third  nerve  is  not  complete.  Thus, 
there  may  be  paralysis  of  the  levator  palpebrae  superioris  muscle,  pro- 
ducing ptosis,  or  the  internal  rectus  muscle  of  the  eyeball  may  be  par- 
alyzed, causing  the  globe  to  be  rotated  outward  by  the  uncompensated 
action  of  the  external  rectus,  and  as  a  consequence  producing  double 
vision;  or,  what  is  more  rarely  the  case,  the  superior  or  inferior  rectus, 
or  the  inferior  oblique,  may  lose  the  power  to  act.  In  a  few  cases,  the 
only  indication  of  the  affection  of  the  third  nerve  is  dilatation  of  the 
pupil. 

The  fourth  nerve  may  be  paralyzed,  and  then  the  loss  of  power  is 
limited  to  the  superior  oblique  muscle,  and  the  ability  to  rotate  the  eye- 
ball outward  and  downward  is  impaired;  and  again,  the  lesion  is  only 
manifested  as  regards  the  sixth  nerve  and  the  external  rectus  muscle, 
so  that  internal  strabismus  is  the  result.  Occasionally  the  first  sign  of 
the  disease  is  aphasia,  with  or  without  vertigo,  confusion  of  ideas,  or 
loss  of  consciousness. 

It  not  infrequently  happens  that  pain  of  a  very  severe  character  is 
for  a  long  time  the  only  symptom  which  disturbs  the  patient.  It  may 
be  located  in  some  part  of  the  head,  or  may  be  referred  by  the  patient 
to  the  face,  and  is  often  regarded  and  treated  as  ordinary  neuralgia. 
The  chief  features  of  this  pain  are  its  intensity  and  persistency.  I  have 
known  it  to  last,  without  interruption,  night  and  day,  for  over  four 
months,  driving  its  subject  to  the  verge  of  insanity,  and  causing  him  to 
entertain  serious  thoughts  of  suicide. 


CHRONIC   CEREBRAL   MENINGITIS.  233 

In  a  few  of  the  cases  which  have  come  under  my  observation,  the 
principal  symptom  was  anaesthesia  of  certain  portions  of  the  cutaneous 
surface.  The  skin  of  the  face  appears  to  be  particularly  liable  to  this 
phenomenon,  although  I  have  seen  it  extend  throughout  the  whole  of 
one  side  of  the  body;  again,  confined  to  the  lower  extremities;  and  at 
other  times  to  the  trunk,  or  upper  extremities.  In  one  case  this  was 
unaccompanied  by  paralysis  of  motion  anywhere,  but  in  the  others  the 
muscles,  or  some  of  them  supplied  by  the  third  nerve,  were  paralyzed. 
In  a  case  reported  by  Petrequin,1  and  cited  by  Lagneau,3  of  syphilitic 
necrosis  of  the  frontal  bone,  and  in  which  there  was  certainly  also 
chronic  basilar  meningitis,  the  lower  limbs  were  deprived  of  sensibility 
for  two  months. 

Vertigo  is  almost  always  a  prominent  symptom,  and  may  be  so  intense 
and  persistent  as  to  prevent  the  patient  walking  without  support.  At 
times  it  is  impossible  for  the  recumbent  position  to  be  abandoned,  even 
for  an  instant,  without  the  supervention  of  severe  dizziness;  at  others 
it  occurs  unexpectedly,  and  may  be  the  cause  of  the  individual  falling. 

The  eyesight  is  often  impaired  from  a  very  early  period.  This  may 
be  due  to  paralysis  of  the  accommodation,  resulting  from  loss  of  power 
in  the  iris  and  ciliary  muscle,  especially  the  latter;  for,  though  the  iris 
probably  has  some  influence  in  effecting  the  adjustment  of  the  lens  for 
different  distances,  it  is  in  the  ciliary  muscle,  as  Von  Graefe  has  shown, 
that  the  function  mainly  resides.  The  defect  in  question  is  shown  by 
the  difficulty  which  the  patient  experiences  in  distinguishing  near  ob- 
jects. There  is  no  trouble  in  seeing  images  at  a  distance,  but  the  effort 
to  read,  for  instance,  is  unsuccessful — the  lines  of  print  appearing 
blurred — and  always  increases  the  pain  in  the  head,  besides  inducing 
temporary  pain  in  the  eye.  The  exact  degree  of  impairment  of  accom- 
modative  power  may  be  ascertained  by  the  use  of  Snellen's  test-type, 
or  still  better  by  Galezowski's  typographical  scales.3 

Or  the  asthenopia  may  be  the  result  of  the  paralysis  of  the  interna] 
rectus  muscle. 

Again,  the  defective  vision  may  be  caused  by  the  disturbance  in  the 
special  nervous  apparatus  of  the  eye.  Examination  with  the  ophthal- 
moscope almost  invariably  reveals  the  existence  of  hyperemia  of  the 
optie  nerve  and  retina,  and  not  infrequently  of  optie  neuritis,  e.i 
by  extension  of  the  morbid  process  from  the  cerebral  membranes  to  the 
optie  nerve.  Sometimes,  as  in  cases  to  be  cited  presently,  vision  may 
be  entirely  lost  from  this  cause;  but,  again,  it  is  indubitable,  as  Dr. 
Hughlinga   Jackson   has   very  definitely  shown,'  that  a  great  d< 

1  Oa-  I  |  386,  tome  It.,  p. 

1  Maladies  typhilitiques  du  systeme  nervous,"  Paris,  1860,  p.  tin. 

Bt  ohromotiqaee  pour.l'examen  de  faculte*  risuelle,"  Pun, 
187-1. 

*  Among  other  places,  In  the  West  Riding  Lunatic  Asylum  Reports,  in  .i  |>.i. 


234  DISEASES  OF  THE  BRAIN. 

of  optic  neuritis  may  exist,  and  yet  the  patient  be  capable  of  minute 
vision. 

The  sense  of  hearing  may  also  become  impaired  or  lost  by  extension 
of  the  inflammation  so  as  to  involve  the  auditory  nerve.  Several 
cases  of  the  kind  have  come  under  my  observation;  and  in  one,  which 
will  be  more  specifically  referred  to  hereafter,  the  function  was  very 
suddenly  regained  under  appropriate  treatment. 

Although  mental  exertion  of  all  kinds-  adds  to  the  severity  of  the 
symptoms,  it  is  not  usually  the  case  that  the  mind  is  primarily  affected 
to  any  considerable  extent.  There  may  be  periods  of  depression  but 
these  are  generally  the  result  of  the  physical  phenomena — the  pain,  ver- 
tigo, paralysis,  etc.,  the  sensations  arising  from  or  the  contemplation  of 
which  are  calculated  to  disturb  the  mental  equanimity.  When,  how- 
ever,  the  mind  is  brought  to  bear  upon  any  subject,  the  intellectual  pro- 
cesses are  as  correct  as  ever,  the  only  difference  being  that  they  cannot 
be  long  continued  without  the  supervention  of  fatigue  and  an  aggrava- 
tion of  the  symptoms. 

It  quite  often  happens  that  the  seat  of  chronic  basilar  meningitis 
changes,  and  with  the  transference  there  is  an  alteration  in  the  locality 
of  the  symptoms.  This  is  especially  seen  in  the  matter  of  paralysis. 
Thus,  in  the  beginning,  the  third  nerve  may  be  paralyzed,  and  eventu- 
ally the  extension  of  the  lesion  leads  to  the  implication  of  the  fourth, 
fifth,  and  sixth.  Cases  In  illustration  of  this  point,  which  have  occurred 
in  my  own  experience,  will  presently  be  adduced.  In  the  mean  time,  the 
following  example  from  Sir  Charles  Bell 1  will  prove  of  interest.  The 
fact  that  Sir  Charles  mistook  the  real  nature  of  the  disease  will  not  de- 
tract from  its  importance.  It  is  reported  as  a  "  Case  of  Disease  of  the 
Nerves  within  the  Orbit. 

"  Martha  Symmonds,  aged  forty-one,  Northumberland  Ward.  This 
woman  was  admitted  into  the  hospital  for  a  disease  apparently  seated  in 
the  left  orbit.  Nine  months  ago  she  had  a  paralytic  stroke,  attended 
with  the  loss  of  power  in  her  left  arm,  neck,  and  face,  on  the  same  side. 
She  lost  also  her  power  of  speech,  excepting  only  to  'babble,'  as  she 
says.  She  recovered  from  this  attack,  and  went  into  service.  About 
eight  or  ten  weeks  ago,  she  was  alarmed  by  a  commencing  dimness  in 
both  her  eyes,  and  she  was  obliged  to  leave  her  place  on  account  of  this 
dimness  of  her  sight.  Both  her  eyes  were  equally  affected,  and  there 
was  no  redness  or  opacity  perceptible  in  either  of  them.  She  placed 
herself  under  a  medical  gentleman,  because  she  dreaded  a  return  of  the 
palsy.     About  six  weeks  ago,  the  upper  eyelid  of  the  left  eye  fell,  and 

tied  "  A  Case  of  Recovery  from  Double  Optic  Neuritis."  The  case  was  probably  one  of 
chronic  basilar  meningitis,  of  syphilitic  origin. 

1  "  The  Nervous  System  of  the  Human  Body.  Embracing  the  Papers  delivered  to  the 
Royal  Society  on  the  Subject  of  the  Nerves,"  London,  1830.  Appendix,  p.  cv.  Edition  of 
1844,  p.  343. 


CHRONIC   CEREBRAL   MENINGITIS.  235 

she  could  not  raise  it.  At  that  time  she  suffered  great  pain  above  the 
left  eye,  and  the  pain  extended  upon  the  left  side  of  her  forehead.  She 
at  the  same  time  lost  the  vision  of  this  eye,  although  she  could  dis- 
tinguish by  it  the  light  of  day  from  darkness.  She  could  direct  the 
motions  of  this  eyeball  as  well  as  of  the  other  at  that  time,  and  the  ap- 
pearance of  the  eye  was  natural. 

"  Five  days  before  she  was  admitted  to  the  hospital  she  experienced 
a  violent,  deep,  throbbing  pain  in  her  left  eye,  and  from  that  time  the 
eyeball,  as  she  says,  became  enlarged,  until  it  projected  considerably 
beyond  the  orbit.  Two  days  before  her  admittance,  she  was  totally 
blind  in  that  eye,  and  was  deprived  of  sensation  on  the  surface  of  the 
whole  eye,  eyelids,  the  internal  corner  of  the  nose,  and  upon  the  left 
side  of  her  forehead. 

"  At  present  her  left  eye  is  covered  with  its  upper  eyelid,  and  pro- 
jects greatly  from  its  natural  situation.  The  lower  eyelid  is  everted  as 
a  consequence  of  the  projection  of  the  ball  of  the  eye,  and  the  conjunc- 
tiva is  tumid  and  projecting.  She  cannot  raise  the  upper  eyelid,  although 
when  it  is  raised  with  her  finger  she  can  squeeze  it  down  again,  and 
winks  with  a  motion  which  corresponds  naturally  with  that  of  the  other 
eye.  It  may  be  a  question  whether  the  globe  of  the  eye  is  enlarged, 
or  only  protruded.  The  pupil  is  unnaturally  large,  and  the  iris  is 
without  motion.  She  cannot  move  the  eyeball  in  any  direction.  The 
whole  eye  is  insensible;  she  has  just  had  her  lower  eyelid  scarified,  and 
she  was  not  sensible  of  pain.  She  allows  us  also  to  press  with  our  finger 
on  the  surface  of  the  eye,  without  complaining  of  any  pain,  or  winking; 
although,  as  we  said  above,  she  can  still  wink,  and  does  wink  with  this 
eyelid  when  the  other  eye  is  threatened. 

"  October  6th. — To-day  some  further  examination  was  made  of  this 
woman's  face  and  head,  in  order  to  ascertain  the  extent  of  insensibility. 
It  was  stated  in  our  last  report  that  she  has  lost  sensation  in  the  sur- 
face of  tin-  I'ft  eye  and  eyelids,  in  the  corner  of  the  nose,  and  upon  the 
forehead.  In  these  parts,  she  says  that  now  the  loss  of  sensation  is  less 
complete,  because  when  she  had  her  eyelid  scarified,  the  other  day,  she 
fell  pain,  which  she  did  not  when  it  was  scarified  before.  The  eye  also 
■eems  diminished  in  size. 

u  Besides  those  parts  which  we  have  already  described  as  being  af- 
fected, she  has,  in  a  partial  degree,  lost  sensibility  to.  touch  in  thai  part 
of  her  check  which  is  just  under  the  orbit, and  dow award  upon  the  side 

of  her  DOSe,  and  upon  the  left  side  of  her  upper  lip,  and  also  within  the 
cavity  of   the  nose  on  the    hit    side.       However,  when    the    point  of    the 

pin  was  brought  near  to  the  ear,  or  upon  the  shin  which  is  over  the 
tower  jaw,  she  then  was  sensible  of  pain.    A  piece  <>f  linen  was  twisted 

so  that   it   might  be  introduced  into  the   h-ft   nostril;   she   allowed   us   to 

push  it  upward  as  far  as  we  could,  and,  during  this  operation,  she  only 
r<  marked  that  she  wis  sensible  of  it    presenoe.    Turning  it  about  with- 


236  DISEASES   OF  THE   BRAIN. 

in  her  nostril  did  not  make  her  sneeze.  When  we  tried  the  same  ex» 
periment  on  the  other  nostril,  she  was  unable  to  bear  the  tickling  pro- 
duced by  the  loose  threads  of  the  cloth,  before  it  was  introduced  into 
the  nostril.  Now  she  informed  us  that  she  is  in  the  habit  of  taking 
snuff;  and  she  is  not  only  insensible  to  its  usually  agreeable  effects,  but 
unconscious  of  its  presence  in  the  left  side  of  the  nose.  We  next  made 
her  close  her  right  nostril,  and  inhale  strong  spirit  of  ammonia;  and 
then  repeated  the  same  experiment  on  the  other  ngstril.  There  was  a 
very  obvious  difference  in  the  effects  produced  by  the  ammonia  on  the 
two  sides  of  the  nose.  She  told  us  she  could  smell  the  ammonia  on 
both  sides,  but  still  she  could  not  bear  to  hold  the  bottle  containing 
the  ammonia  so  long  at  the  right  nostril  as  we  observed  that  she 
could  at  her  left.  When  the  bottle  was  placed  under  the  right  nostril, 
its  pungency  affected  her  almost  immediately,  so  much  that  she  could 
not  bear  it;  on  the  other  hand,  she  allowed  it  to  remain  for  a  consider- 
able time  under  the  left  nostril,  and  even  snuffed  it  up  strongly  before 
she  was  inclined  to  remove  it.  During  these  experiments,  we  observed 
that  the  right  eye  became  suffused  with  tears;  the  left  eye,  on  the  con- 
trary, appeared  to  be  dry  on  its  surface. 

"  In  order  to  ascertain  further  to  what  degree  her  sense  of  smelling 
was  affected,  we  tried  the  effect  of  some  substances  which  possess  odor 
without  pungency.  On  applying  oil  of  anise-seed  to  her  left  nostril, 
while  the  right  one  was  shut,  she  inhaled  it  powerfully,  but  was  sen- 
sible of  no  smell.  Then  a  piece  of  asafcetida  was  tried,  but  still  she  had 
no  kind  of  sensation,  either  pleasant  or  the  reverse.  She  was  sensible  to 
these  odors  in  her  right  nostril. 

"The  state  of  her  mouth  was  examined;  with  the  point  of  a  pencil 
we  pressed  against  the  upper  gums,  on  the  left  side  of  her  mouth,  and 
the  inside  of  her  cheek,  where  it  is  reflected  off  the  gums,  and  she  ap- 
peared to  have  very  slight  or  no  sensation  at  all.  She  volunteered  to 
put  a  spoonful  of  mustard  between  her  gums  and  her  cheek,  and  she 
seemed  very  little  incommoded  by  such  an  experiment.  The  sensibility 
of  the  other  parts  of  her  mouth  was  natural. 

"  The  circumstances  of  this  case,"  continues  Sir  Charles,  "  make  it 
difficult  to  determine  exactly  where  the  disease  is  seated,  which  thus 
produces  the  destruction  of  the  optic  nerve,  the  third  and  fourth  nerves, 
the  first  and  second  divisions  of  the  fifth  nerve,  and  the  sixth  nerve. 
Among  these  nerves  we  might  add  the  olfactory  nerve;  but  it  may  be  a 
question  whether  ^he  function  of  that  nerve  is  directly  or  indirectly 
affected:  the  issue  of  the  case  will  probably  determine  this  matter. 
However,  from  the  condition  of  the  parts  without  the  orbit,  we  observe 
that  the  power  of  closing  the  eyelid  and  winking  is  retained,  when  the 
power  of  raising  the  eyelid  is  gone,  and  the  sensibility  of  the  eyelids 
and  of  the  eye  itself  is  completely  lost.  It  is  the  portio  dura  which  is 
distributed  to  the  orbicular  muscle  of  the  eyelid,  and  bestows  the  pewet 


CHRONIC   CEREBRAL   MEXIXGITIS.  237 

of  winking.  We  see  also  that  she  can  inhale  powerfully,  and  can  per- 
fectly move  the  muscles  belonging  to  the  nostril  and  upper  lip  of  the 
left  side,  when  at  the  same  time  the  skin  which  covers  these  parts  is 
insensible.  Still,  that  power  belongs  to  the  portio  dura.  This  nerve, 
passing  to  the  face  by  a  circuitous  way,  and  being,  therefore,  uninjured 
by  pressure  within  the  orbit,  permits  her  to  move  the  left  nostril  and 
side  of  her  mouth  in  a  natural  correspondence  with  the  other  side  of 
her  face,  although  both  the  first  and  second  divisions  of  the  fifth  nerve 
are  included  in  the  disease,  and  are  destroyed  along  with  the  first,  sec- 
ond, third,  fourth,  and  sixth  nerves. 

"  May  20, 1829. — Since  she  left  the  hospital  she  has  been  a  constant 
sufferer.  The  pain  in  her  head  has  never  left  her;  it  is  principally 
seated  over  both  her  eyes,  and  over  the  left  in  particular.  For  three 
years  she  has  observed  that  this  pain  is  aggravated  for  a  fortnight  be- 
fore her  monthly  periodical  return;  she  says  she  does  not  know  what 
to  do,  her  suffering  is  so  great.  The  pain  varies  in  a  remarkable  man- 
ner with  the  changes  of  the  weather:  she  knows  when  rain  is  approach- 
ing by  the  increase  of  the  pain,  and  immediately  after  it  is  over  the 
pain  is  relieved.  She  has  not  had  a  return  of  the  loss  of  speech,  or  of 
the  paralysis  of  her  arm,  since  she  left  the  hospital,  but  she  has  had  fits 
and  she  has  suffered  from  cramps  in  the  back  of  her  neck  and  right 
breast.  The  arm,  which  was  formerly  paralytic,  becomes,  about  once  a 
month,  numbed  in  such  a  manner  that  she  cannot  use  her  fingers,  and 
this  is  accompanied  with  great  pain.  These  attacks  do  not  last  for  more 
than  five  minutes.     She  walks  quite  well. 

"  The  loss  of  sensation  is  principally  in  the  forehead ;  when  pricked 
with  a  sharp  point  in  any  part  as  high  up  as  the  crown  of  the  head,  she 
has  no  feeling;  but  in  the  temples,  and  below  the  orbits,  and  on  the 
nose,  she  retains  sensation.  The  left  eye  is  blind;  the  pupil  large  ami 
immovable;  the  motions  of  it  are  gone;  the  surface  is  insensible;  it  is 
clear,  and  it  remains  fixed  in  the  centre  of  the  orbit." 

This  woman  entered  the  Middlesex  Hospital  in  October,  1824.  In 
tin-  third  edition  of  Sir  <  iharles  Bell's  work,  published  in  is  1 1,  the  Core- 
going  particulars  are  given,  and  the  history  is  resumed  by  .Mr.  Shaw,  as 
he  observed  her  in  .June,  183G.  At  this  time  then'  was  no  marked 
ohan  i  that,  from  an  inflammation  of  the  right  eye,  Bhe  bad  lost 

the  sight,  and  had  beoome  entirely  blind. 

That  this  ease  was  not  one  of  disease  within  the  orbit  is  sufficiently 
apparent  from  a  consideration  of  the  symptoms,  almost  all  of  which 
point  to  intra-oranial  lesion.  The  extensive  paralysis  of  motion  an. I  of 
sensibility,  the  epileptic  convulsions,  the  oramps,  the  aphasia,  arc  so 
many  circumstances  against  the  correctness  of  Sir  Charles  Bell's  diag- 
.  That  the  morbid  condition  was  inflammation  of  the  basilar  surface 
of  the  cerebral  membranes  is  extremely  probable,  as  much  so  upon  this 
principle  "I'  exclusion  u  from  a  consideration  of  the  positive  symptoms. 


238  DISEASES   OF  THE   BRAIN. 

In  a  case  which  I  saw  in  consultation  with  Dr.  H.  Knapp,  of  this 
city,  the  patient,  a  young-  man,  in  whom  there  was  no  history  or  even 
suspicion  of  syphilis,  was  attacked  with  severe  pain  in  the  head,  at- 
tended with  dimness  of  vision  in  both  eyes.  In  the  next  place  the 
third  pair  of  nerves  became  involved,  causing-  paralysis  of  all  the  ocu 
lar  muscles  supplied  by  these  nerves  on  both  sides,  and  of  both  eyelids 
and  also  producing  dilatation  of  both  pupils.  Next  both  fourth  nerves 
were  affected;  then  the  fifth  pair  causing  facial  anaesthesia  and  paralysis 
of  the  temporal  and  masseter  muscles  on  both  sides;  then  the  sixth,  and 
eventually  the  seventh  and  eighth,  resulting  in  paralysis  of  both  exter- 
nal recti  muscles,  double  facial  paralysis,  and  loss  of  hearing  in  both 
ears.  There  was,  therefore,  in  this  very  remarkable  case,  a  gradual  ad- 
vance of  the  morbid  process,  through  a  period  of  several  weeks,  along 
the  base  of  the  brain,  from  the  antei'ior  to  the  posterior  region.  With 
all  these  symptoms  there  was  not  the  slightest  mental  derangement; 
neither  was  there  paralysis  of  any  other  muscles  than  of  those  supplied 
by  the  nerves  specified.  Shortly  after  I  saw  him  the  pneumogastric 
nerves  became  implicated,  and  death  soon  'ensued.  Unfortunately, 
there  was  no  post-mortem  examination,  but  Prof.  Knapp  and  myself 
agreed  that  the  case  was  one  of  inflammation  of  the  membranes  cover- 
ing the  basilar  surface  of  the  brain. 

In  the  case  of  a  woman  who  came  to  my  clinique  in  the  winter  of 
1871-'72,  the  principal  symptoms  were  deep-seated  pains  in  the  head, 
vertigo,  and  paralysis  of  the  third  nerve  on  the  left  side,  as  evidenced 
by  ptosis,  dilatation  of  the  pupil,  and  external  strabismus,  the  latter 
condition  producing  diplopia.  Conjoined  with  these  symptoms  there 
was  slight  but  decided  paralysis  of  the  muscles  of  the  face,  arm,  and  leg 
of  the  opposite  side,  together  with  cutaneous  anaesthesia.  Inquiry 
showed  that  these  symptoms  had  been  of  very  gradual  development. 
There  was  no  history  of  syphilis  in  the  case.  I  was  of  the  opinion  that 
the  disease  was  chronic  basilar  meningitis,  and  gave  an  unfavorable 
prognosis;  prescribing,  however,  the  iodide  of  potassium  in  large  doses. 

The  following  year  she  returned,  but  this  time  the  sixth  nerve  was 
affected,  causing  internal  strabismus;  and  the  ptosis,  paralysis  of  the  in- 
ternal rectus,  and  the  dilatation  of  the  pupil,  had  entirely  disappeared. 
The  other  symptoms  had  for  a  time  been  very  greatly  relieved  by  the 
treatment,  but  had  reappeared  in  considerable  intensity  about  two 
months  previously. 

In  another  instance,  this  migratory  character  of  the  disease  was 
well  shown.  The  case  was  that  of  a  young  man,  a  private  patient,  but 
whom  I  showed  to  the  class  attending  my  clinique.  He  came  to  me 
originally  with  external  strabismus,  ptosis,  and  dilatation  of  the  pupil 
of  the  left  eye,  together  with  defective  accommodation.  Examination 
with  the  ophthalmoscope  showed  the  existence  of  optic  neuritis,  rather 
slight  in  character,  but  yet  decided,  in  both  eyes.     He  had  also  the  most 


CHRONIC   CEREBRAL   MENINGITIS.  239 

intensely  agonizing  pain  in  the  head  that  has  ever  come  under  my  ob- 
servation, with  vertigo,  frequent  attacks  of  vomiting,  and  paresis  if 
not  paralysis  of  the  left  arm  and  leg.  A  consideration  of  his  condition 
led  me  to  the  diagnosis  of  a  cerebral  tumor,  and  I  accordingly  gave  a 
very  unfavorable  prognosis.  I  was  led  to  this  conclusion  not  so  much 
from  the  motorial  derangement,  as  from  the  atrocious  cephalalgia  from 
which  the  patient  suffered.  In  this  case  there  was  some  slight  suspi- 
cion of  syphilis,  and  I  treated  him  with  mercury  and  large  doses  of  the 
iodide  of  potassium.  In  a  short  time  the  pain  in  his  head  disappeared, 
and  in  a  few  weeks  there  were  no  indications  of  paralysis  anywhere;  in 
fact,  he  was  to  all  appearances  perfectly  cured.  But  at  the  end  of  two 
or  three  months  he  reappeared,  with  the  corresponding  set  of  symptoms 
in  the  right  eye  and  right  side  of  the  body,  and  with  pain  in  the  head 
fully  as  severe  as  that  which  had  characterized  the  previous  attack.  I 
again  treated  him  with  mercury  and  the  iodide  of  potassium,  and  his 
symptoms  again  disappeared.  He  remained  well  for  two  years,  when 
he  had  another  attack,  of  which  he  was  entirely  relieved  by  the  iodide 
of  potassium. 

In  this  case,  the  history  of  which  points  strongly  to  a  syphilitic 
origin,  there  were  probably  inflammation  and  thickening  of  the  mem- 
branes  at  the  base  of  the  brain,  and  presumably  gummy  formations. 

The  fact  that  the  inflammation  sometimes  alternates  with  skin-erup- 
tions is  interesting,  and  has  been  repeatedly  noted.  A  case  of  the 
kind  was  not  long  since  under  my  care.  It  was  that  of  a  gentleman 
who  had  attacks  of  acute  pain  in  the  head,  accompanied  with  all  the 
phenomena  of  paralysis  of  the  left  third  nerve.  There  was  effusion  of 
lymph  upon  both  optic  disks,  the  result  probably  of  old  optic  neuritis. 
Curiously  enough,  these  attacks  alternated  with  an  eczcmatous  affec- 
tion, involving  the  trunk  and  especially  the  breast.  On  the  disappear- 
ance of  th<-  skin-disease  under  remedial  measures,  his  head-symptoms 
immediately  recurred,  and,  when  they  were  relieved  by  the  action  of  the 
iodide  of  potassium,  he  was  again  attacked  with  eczema. 

'  )f  the  forty-seven  cases  of  basilar  meningitis  collected  by  Gintrao,1 
ral  of  them  were  distinctly  chronic  in  character.  As  post-mortem 
examinations  were  made  in  these  cases,  they  will  be  more  appropriately 
considered  under  the  head  of  morbid  anatomy  and  pathology. 

Causes. — The  causes  of  chronic  basilar  meningitis  are  generally 
sufficiently  apparent.  It  may  result  from  an  acute  at  lack,  bul  this 
is  not  a  usual  mode  of  origin,  for  the  reason  already  stated,  that  death 
is  ordinarily  the  consequence  of  such  an  affection.     The  most  common 

cause  in  my  experience,  is  syphilis;  next,  the  inordinate  use  of  alcoholic 

liquors;  and  next  excessive  emotional  disturbance,  such  for  instance  as 
business  anxieties.     Then  next  in  point  of  Erequenoy  oome  atmospheric 

vicissitudes,  I. lows  on  the  he;ld,  and  attacks  of  other  diseases,  as  sea  He  t 
1  Op.  cit.,  tonic  ii.,  p.  077. 


240  DISEASES   OF   THE   BRAIN. 

fever,  and  especially  epidemic  cerebro-spinal  meningitis,  and  suppura- 
tive otitis.  Men  are  more  subject  to  it  than  women,  and  adults  more 
than  children.     Frequently  no  cause  can  be  assigned. 

Diagnosis. — Chronic  basilar  meningitis  is  not  liable  to  be  con- 
founded with  any  other  cerebral  affection  except  tumors,  especially 
those  of  a  syphilitic  character,  situated  at  the  base  of  the  brain,  and 
chronic  softening,  arising  from  thrombosis  of  the  basilar  arteries,  and 
diseases  of  the  capillaries. 

From  non-syphilitic  tumors  it  may  be  distinguished  by  the  fact  that 
the  paralysis  is  less  extensive,  that  the  pain  is  not  usually  so  severe, 
that  the  vertigo  is  not  so  intense  or  persistent,  and  that  the  dis- 
turbances of  vision  are  not  so  profound.  In  a  word,  the  symptoms  of 
chronic  basilar  meningitis  are  less  pronounced  than  those  of  tumors  at 
the  base  of  the  brain,  while  at  the  same  time  they  are  ordinarily  de- 
veloped with  greater  rapidity.  Another  mark  of  difference  is  the  fact 
that  tumors,  non-syphilitic  in  character,  do  not  yield  to  remedial  meas- 
ures, while  chronic  basilar  meningitis  often  does,  and  is  generally  miti- 
gated by  proper  treatment. 

From  tumors  of  a  syphilitic  nature,  or  gummata,  as  they  are  called, 
the  diagnosis  is  difficult,  if  in  fact  there  is  any  real  distinction  existing 
between  them  and  basilar  meningitis  of  syphilitic  origin.  A  gummy 
tumor  situated  at  the  base  of  the  brain  can  scarcely  exist  without  the 
production  of  basilar  meningitis,  so  that  the  symptoms  such  as  have 
been  described,  present  in  a  person  having  the  clinical  history  of  syphi- 
lis, are  either  the  result  of  simple  chronic  meningitis,  or  of  meningitis, 
associated  with  one  or  more  gummy  tumors.  Virchow  '  goes  so  far  as  to 
doubt  if  even,  where  after  death  we  find  only  meningitis,  the  condition 
has  not  been  preceded  by  a  gummatous  affection  which  has  disappeared. 
The  further  consideration  -of  this  point  will  be  more  proper  under  the 
head  of  morbid  anatomy. 

Where  there  is  no  history  of  syphilis,  of  course  the  question  of  the 
existence  or  non-existence  of  syphilitic  tumors  will  not  arise. 

From  thrombosis  of  the  arteries  at  the  base  of  the  brain,  and  from 
such  diseases  of  the  capillaries  in  the  same  situation  as  have  been  de- 
scribed in  the  previous  chapter,  chronic  basilar  meningitis  is  scarcely 
distinguishable  during  the  life  of  the  patient.  When  these  are  syphi- 
litic in  character,  the  two  conditions  generally  coexist.  Sooner  or 
later,  however,  the  former  affections  terminate  in  death,  and  the  phe- 
nomena to  which  they  give  rise,  though  sometimes  remitting  in  violence, 
are  clearly  not  lessened  in  severity  by  medical  treatment.  As  regards 
other  affections,  the  history  of  the  case  will  generally  be  a  sufficient 
guide  to  a  correct  diagnosis. 

Prognosis. — The  prognosis  is  very  much  influenced  by  the  etiology. 
Those  cases  which  result  from  injuries  generally  terminate  fatally,  as  do 
1  "Pathologie  des  tumeurs,  traduit  de  l'AUeinand,"  Paris,  I860,  tome  ii.,  p.  440. 


CHRONIC   CEREBRAL   MENINGITIS.  241 

those  due  to  the  excessive  use  of  alcoholic  liquors,  especially  if  the  habit 
be  continued.  When  induced  by  mental  influences  the  prognosis  is 
generally  more  favorable,  provided  the  patient  can  be  subjected  to  the 
hygienic  operation  of  rest,  travel,  change  of  associations,  etc.  Syphilitic 
basilar  meningitis,  if  seen  sufficiently  early  and  subjected  to  proper 
treatment,  usually  terminates  in  recovery.  Subsequent  attacks,  which 
are  always  liable  to  occur,  do  not  in  general  run  so  favorable  a  course. 
In  all  cases  a  great  deal  depends  upon  the  duration  of  the  disease. 
When  of  long  standing  the  morbid  changes  in  the  tissues  involved  have 
usually  become  so  profound  that  recovery  is  not  a  probable  sequence. 

The  age  of  the  patient  is  likewise  an  important  point  in  the  prog 
nosis  ;  and,  other  things  being  equal,  individuals  of  advanced  years  are 
not  so  apt  to  recover  as  those  of  middle  life.     In  children  a  fatal  termi- 
nation is  to  be  expected. 

Those  cases  which  are  due  to  the  extension  of  inflammation  from  the 
ear  almost  invariably  end  in  death,  as  do  those  ensuing  upon  epidemic 
cerebro-spinal  meningitis.  Latterly,  however,  I  have  had  under  my 
charge  two  cases,  resulting  from  cerebro-spinal  meningitis,  in  which  it 
has  taken  place,  though  with  very  marked  impairment  of  vision  from 
double  optic  neuritis  in  both,  and  of  hearing  in  one. 

Morbid  Anatomy. — The  morbid  anatomy  of  chronic  basilar  menin- 
gitis does  not  differ  in  many  respects  from  the  corresponding  affection 
cf  the  convex  surface  of  the  brain.  It  is,  however,  generally  much 
more  circumscribed  in  its  extent,  and  may  be  restricted  to  a  portion  of 
the  membranes  not  larger  than  a  dime  in  circumference.  In  one  form 
the  affected  tissues  are  thickened  and  opaque,  and  there  is  an  exudation 
of  serous  or  gelatiniform  fluid  ;  in  another  the  exudation  is  puriform  ; 
and  In  a  third  it  is  thick  and  gummy,  constituting  the  so-called  gummy 
tumor  of  syphilitic  origin. 

The  serous  or  gelatiniform  exudation  often  shows  a  tendency  to  be- 
come organized  and  to  present  a  membraniform  appearance,  or  even  to 
assume  a  still  more  solid  form.  Gintrac  cites  from  Simon  '  the  case  of  a 
woman,  thirty-five  years  old,  who  for  .six.  years  had  bdbn  subject  to 
paroxysms  of  intense  cephalalgia.  Two  years  subsequently  she  became 
blind  on  the  1  and  for  two  months  afterward  Buffered  still  i 

severely  from  pain  in  the  head  ;  then  she  lost  the  sight  of  her  right  eye, 
15oth  bides  remained  contractile.  The  sense  of  smell  was  lost,  though 
the  pituitary  membrane  retained  its  tactile  sensibility.  Bearing,  taste, 
nnd  touch,  were  unaffected.     Coma  supervened,  in  which  sh.-  died.     On 

tination,  the   dipltte   and  the  membranes    were    found   oong 

The  arachnoid  and  the  ventricles  contained  an  excess  of  serous  exuehv 

tion.      In  the  pia  mat  >r  there  was  ,-i  deposit  of  a  whiti  fibrinous 

banoe.  whi  id  the  course  of  the  middle  cerebral  vessel*,  and 

layover  the  chiasma  of  the  optic  nerves,  the  I  mammillaria, and 

1  "  Bulletin  de  la  sudrtu  anatomlque,"  1845,  p.  196. 


242  DISEASES   OF   TUE   BRAIN. 

the  anterior  perforated  spaces.  The  optic  and  olfactory  nerves  were 
atrophied  and  the  chiasma  deformed  ;  the  retinae  were  normal. 

Usually  the  membranes  are,  in  some  places,  firmly  adherent  to 
each  other,  and  not  infrequently  to  the  cortical  substance  of  the 
brain,  in  which  case  the  latter  is  softened  to  such  an  extent  as 
to  tear  away  when  the  attempt  is  made  to  separate  the  membranes 
from  it. 

When  the  exudation  is  puriform  in  character  it  occasionally  be- 
comes thick,  and  appears  as  semi-solidified  plates  in  various  situations. 

The  exudation,  whatever  its  nature,  may  be  deposited  between  the 
layers  of  the  arachnoid,  in  the  sub-arachnoid  space,  or  in  the  meshes 
of  the  pia  mater.  Its  seat  may  be  any  part  of  the  base  of  the  brain, 
but  its  usual  situations  are  the  chiasma  of  the  optic  nerves,  along 
the  course  of  these  nerves,  on  the  tuber  cinereum,  the  corpora  mam- 
miliaria,  and  between  the  crura  cerebri.  Sometimes  it  extends  anteri- 
orly along  the  course  of  the  olfactory  nerves,  laterally  into  the  fissure 
of  Sylvius,  and  posteriorly  as  far  as  the  pons  Varolii  and  medulla 
oblongata. 

In  the  syphilitic  form  of  the  disease  it  is  a  matter  of  some  doubt 
whether  the  gummy  exudation  is  the  result  of  the  specific  inflamma- 
tion of  the  membranes  or  whether  the  inflammation  is  excited  by  the 
presence  of  the  new  formation.  Gintrac1  seems  inclined  to  doubt 
the  existence  of  syphilitic  meningitis,  though  he  admits  the  possi- 
bility of  its  occurrence.  For  him  there  is  no  syphilitic  meningitis  un- 
less its  presence  be  demonstrated  by  a  post-mortem  examination  and 
its  characteristics  definitely  established,  while  others  give  a  specific 
nature  to  any  inflammation  of  the  meninges — and,  in  fact,  to  any 
other  affection — occurring  in  a  person  who  at  any  time  has  been  the 
subject  of  syphilis.  In  my  opinion,  cerebral  meningitis  may  be  in- 
duced by  the  syphilitic  diathesis,  and  thus  be  a  syphilitic  meningitis, 
and  it  may  exist  as  a  non-specific  affection  in  an  individual  who  has 
had  an  infecting  chancre.  Undoubtedly  there  are  cases  of  meningitis 
occurring  in  syphilitic  persons  that  are  no  more  under  the  influence 
of  anti-syphilitic  treatment  than  the  cases  happening  in  otherwise 
healthy  individuals.  Fox,5  however,  states  it  as  his  opinion  that  it  is 
at  best  an  open  question  whether  meningitis  ever  occurs  indepen- 
dently of  syphilis,  rheumatism,  alcoholic  poisoning,  tubercle,  anajmia, 
or  mechanical  irritations. 

But,  in  regard  to  the  morbid  anatomy  of  chronic  basilar  menin- 
gitis of  syphilitic  etiology,  Virchow3  has  supplied  very  important 
data  in  his  remarks  on  syphilitic  tumors  of  the  brain  and  its  mem- 
branes. 

1  Op.  city  tome  iii.,  p.  100. 

2  "The  Pathological  Anatomy  of  the  Nervous  Centres,"  London,  1874,  p.  65. 

3  Op.  cil.,  p.  437  et  scq. 


CHRONIC   CEREBRAL   MENINGITIS.  243 

The  gummy  tumors  are  seen  most  frequently  at  the  base  of  the  brain. 
Sometimes  they  are  very  exactly  defined  in  their  boundaries,  and  then 
they  arc  tumors  in  the  true  sense  of  the  word  ;  but  ordinarily  they  are 
more  diffused,  and  are  accompanied  with  the  phenomena  of  inflamma- 
tion, a  fact  which  seems  to  distinguish  them  from  the  true  tumor.  As 
already  stated,  Virchow  regards  this  condition  as  a  "  gummy  inflamma- 
tion;" and  even  when  the  exudation  is  not  present,  and  the  appear- 
ances are  those  cf  a  non-specific  inflammation  of  the  membranes,  the 
question  may  arise  whether  or  not  the  gummy  exudation  has  not  been 
the  first  step  in  the  morbid  process,  but,  having  been  absorbed,  has  left 
only  doubtful  traces  of  its  presence.  With  the  true  gummy  tumor  wo 
are  not  at  present  concerned. 

The  most  common  seat  of  syphilitic  basilar  meningitis  is  the  region 
bounded  anteriorly  by  the  chiasma  of  the  optic  nerves,  and  posteriorly 
by  the  crura  of  the  cerebellum.  Hence  it  is  that  the  nerves  lying  at  the 
base  of  the  brain,  and  especially  the  third  pair,  are  so  liable  to  be  im- 
plicated. This  latter,  from  its  exposed  situation,  running  as  it  does 
from  the  crura  cerebri  to  the  orbit,  can  scarcely  escape  being  involved 
in  the  morbid  process. 

Pathology, — The  functions  of  the  nerves  at  the  base  of  the  brain  are 
so  well  understood  that  the  connection  of  the  symptoms  of  chronic 
basilar  meningitis  with  the  morbid  condition  constituting;  the  disease  is 
sufficiently  apparent  in  the  great  majority  of  cases.  The  circumscribed 
character  of  the  inflammation  enables  us  also  to  determine  its  seat  with 
accuracy,  and  its  migrations  can  be  marked  with  considerable  certainty, 
■ably  in  the  very  earliest  stage  of  the  disease  these  points  cannot 
always  be  clearly  made  out,  for  the  principal  phenomenon  is  ccntrio 
pain,  dm;  to  congestion,  and  it  is  difficult  to  locate  the  seat  with  exact- 
ness ;  but,  as  the  affection  advances  to  its  full  development,  effusion 
takes  place,  and  then  the  eccentric  symptoms  become  more  prominent 
if  they  do  not  at  this  time  make  their  appearance.  These  we  have  seen 
consist  of  disturbances  of  sensibility  and  of  motility  in  those  parts  of 
the  body  Bupplied  by  the  nerves  at  the  base  of  the  brain,  or  of  aphasia 
from  nsion  of  the  inflammation  along  the  fissure  of  Sylvius  to 

the  island  of  I'eil,  or  parts  of  the  brain  in  its  immediate  vicinity.  It  is 
only  at  a  still  later  period,  when  the  morbid  process  has  directly  or  in- 
directly involved  (lie  crura  cerebri,  or  lias  vprcal  to  the  convexity  of 
the  brain,  thai  -'liability  or  motility  is  disturbed  in  the  trunk  and 
limb-. 

When  the  sense  of  smell  is  deranged,  the  lesion  exists  upon  the 
earn  •  Bide  a-  the  Bymptoms,  for,  as  we  know,  the  olfactory  nervea  do 
not  decqssate. 

When  vision  i>  impaired  from  optic  neuritis,  we  cannol  be  so  sure 
as  to  the  side  upon  which  the  disease  exists.  For  we  may  have  optic 
neuritis  as  che  consequence  of  disease  in  distanl    parts  of  the  brain,  as 


244  DISEASES   OF  THE   BRAIN. 

well  as  from  the  direct  implication  of  the  optic  nerves  in  the  patho- 
logical condition  ;  and  even  when  this  latter  is  the  case,  owing  to  the 
incomplete  decussation  of  these  nerves,  it  is  possible  for  optic  neuritis 
to  exist  in  conjunction  with  a  homolateral  or  a  heterolateral  lesion. 

The  symptoms  due  to  the  involution  of  the  third  pair  of  nerves  are 
manifested  as  regards  the  upper  eyelid,  which  becomes  paralyzed  and 
drops  over  the  eye,  the  muscles  of  the  globe,  except  the  external  rectus, 
and  the  pupil,  which  is  dilated,  owing  to  the  paralysis  of  the  circular 
fibres  of  the  iris,  which  receive  their  motor  influence,  through  the  third 
nerve,  from  the  ophthalmic  ganglion. 

The  third  pair  of  nerves  have  their  apparent  origin  in  the  crura 
cerebri,  the  right  nerve  from  the  right  crus,  and  the  left  nerve  from 
the  left  crus.  If,  however,  the  fibres  be  followed  out  by  minute  dis- 
section, it  will  be  seen  that  their  true  origin  is  from  a  large  nucleus 
situated  in  the  ventral  portion  of  the  gray  matter  surrounding  the 
aqueduct  of  Sylvius.  This  nucleus  is  composed  of  a  number  of  groups 
of  cells,  each  one  of  these  groups  supplying  a  different  ocular  muscle. 
Each  nucleus  of  one  side  innervates  the  ocular  muscles  on  the  same 
side  with  one  exception.  According  to  Spitzka,1  it  is  demonstrated 
that  in  animals  with  conjugated  lateral  eye  movements  the  origin  of 
each  third  nerve  is  not  limited  to  the  nidi  of  its  side  ;  a  part  is  decus- 
sated, and  the  decussated  origin  is  related  to  the  innervation  of  the  in- 
ternal rectus.  This  decussation  occurs  within  the  pes  ;  therefore  each 
nerve,  at  its  exit  from  the  pes,  contains  its  full  complement  of  fibres. 
The  pes  also  contains  the  motor  and  sensory  fibres  which  supply  the 
opposite  side  of  the  body.  Disease  involving  one  pes  would  therefore 
cause  derangement  of  motility  in  the  muscles  supplied  by  the  corre- 
sponding third  nerve,  and  of  sensation  and  motion  in  the  opposite 
halt'  of  the  body  ;  alternate  or  cross-paralysis  would  therefore  be  the 
result.  As  chronic  basilar  meningitis  often  involves  the  membrane 
covering  a  pes,  cross-paralysis  is  frequently  a  phenomenon  of  the 
disease. 

In  those  cases  in  which  there  is  no  paralysis  anywhere  except  in 
the  muscles  supplied  by  the  ocular  motor  nerve,  the  lesion  must  exist 
anteriorly  to  the  pes,  and  affect  the  trunk  of  the  nerve  of  the  same 
side  as  that  of  the  paralyzed  muscles. 

It  is  not  often  the  case  that  the  fourth  nerve,  or  trochlearis,  is  alone 
involved,  though  one  such  case  has  come  under  my  observation.  In 
this  the  patient  had  no  marked  symptom  of  any  kind,  except  that  in  a 
certain  position  of  his  head  he  saw  double.  On  examination,  I  ascer- 
tained that,  when  he  turned  his  head  toward  the  left  shoulder,  he  saw 
double,  and  hence  I  diagnosticated  paralysis  of  the  left  superior  oblique 
muscle.  Further  experiments  confirmed  this  opinion,  and  the  diagnosis 
of  chronic  basilar  meningitis  was  shown  to  be  correct  by  the  extension 
1  "ITistology  of  the  Brain."     Rcf.  "Ilandb.  Med.  Scien.,"  vol.  viii.,  1S89. 


CHRONIC   CEREBRAL   MENINGITIS.  245 

of  the  disease  so  as  to  involve  the  third  nerve,  and  by  the  supervention 
of  pain  and  other  phenomena  of  the  affection  in  question. 

The  sixth  nerve,  or  abducens,  is  not  infrequently  the  only  nerve 
implicated  in  the  lesion,  and  then  there  is  internal  strabismus  from 
paralysis  of  the  external  rectus  muscle.  Several  such  cases,  in  which 
there  were  the  concomitant  symptoms  of  chronic  basilar  meningitis, 
have  come  under  my  notice.  The  case  of  one  of  these,  a  woman,  who 
formed  the  subject  of  a  clinical  lecture,  has  already  been  cited.  An- 
other case  was  that  of  a  man,  the  subject  of  syphilis,  and  in  whom  the 
lesion  was  only  manifested  as  regarded  the  external  rectus  muscle. 
There  were  no  head-symptoms  of  any  kind.  The  paralysis  had  ensued 
during  the  night,  and  the  patient  awoke  in  the  morning  to  find  that  he 
had  internal  strabismus  and  double  vision.  He  recovered  entirely  under 
the  use  of  large  doses  of  the  iodide  of  potassium.  But  on  the  10th  of 
January,  1875,  he  had  an  epileptiform  paroxysm,  and  this  was  several 
times  repeated  during  the  following  week.  Under  the  influence  of  the 
iodide  of  potassium,  conjoined  with  the  bromide,  he  has  for  the  past  two 
months  had  no  return  of  the  convulsions  ;  but  his  mind  is  somewhat 
confused,  and  he  has  occasional  severe  pain  in  the  head. 

The  seventh,  or  facial  nerve,  is  sometimes  embraced  in  the  morbid 
process,  giving  rise  to  paralysis  of  one  or  mpre  of  the  muscles  on  one 
side  of  the  face,  which  it  supplies.  In  one  instance,  apparently  the  re- 
sult of  syphilitic  basilar  meningitis,  which  came  under  my  charge  in 
December,  1874,  both  facial  nerves  were  involved,  and  there  was  conse- 
quently double  facial  paralysis. 

The  eighth,  or  auditory  nerve,  also  occasionally  gives  evidence  of 
loss  or  impairment  of  its  function;  but,  unless  special  examination  rela- 
tive to  the  hearing  be  made,  or  both  nerves  be  involved,  the  lesion,  as 
ids  this  nerve,  may  escape  detection,  as  patients  very  often,  even 
when  the  hearing  is  entirely  destroyed  in  one  ear,  are  unaware  of  the 
fact,  and  persist  that  it  is  unimpaired. 

The  ninth,  tenth,  and  eleventh  pairs  of  nerves  are  not  so  apt  to  be 
ill  in  chronic  basilar  meningitis  as  some  of  the  others,  for  (he  rea- 
sons that  (heir  relations  with  the  interior  of  the  cranium  are  not  so  in- 
timate, and  that  the  seat  of  the  disease  is  generally  anterior  to  their 
situation. 

Should  the  ninth,  or  glosso-pliarvn-^e.-il  nerve,  l»e  involved,  (hero 
Would  be  loss  or  impairment  of  the  sense  of  taste  upon  the  con,'. 
sponding  side,  and  the  implication  of  the  pneumogastric  would  lead  to 
a  complicated  series  of  phenomena,  of  whiohthe  chief  would  be  pal- 
pitation of  the  heart,  irregularity  of  the  respiration,  and  derangement 
of  the  function  of  digestion;  while,  if  the  Bpinal  accessary  were  reached 
by  the  morbid  process,  there  would  he  difficulty  of  swallowing,  ami 
perhaps  alteration  in  the  timbre  of  the  voice. 

Tic-  hypoglossal,  or  sublingual  aerve,  is  occasionally  affected,  pro- 


246  DISEASES   OF  THE   BRAIN. 

ducing  paralysis  of  the  side  of  the  tongue  corresponding-  to  the  situa- 
tion of  the  disease. 

When  the  fifth  nerve  is  involved,  the  chief  manifestations  of  its 
lesion  are  relative  to  sensation.  Thus  there  are  either  intense  neuralgic 
pains  in  some  part  of  the  cutaneous  surface  of  the  head  or  neck,  or 
there  is  equally  well-marked  anaesthesia.  The  former  condition  is  by 
far  the  more  frequent.  From  some  cause  or  other,  the  motor  fibres  of 
this  nerve  almost  invariably  escape,  and  thus  the  temporal  and  masseter 
muscles  are  not  paralyzed.  I  have,  however,  already  cited  a  case  in 
which  they  were  affected. 

The  general  relation  of  the  symptoms  of  chronic  basilar  meningitis 
with  the  lesion  constituting  the  disease  is  Avell  shown  in  several  of  the 
cases  cited  by  Gintrac.  Thus  he  quotes  one  from  Bossu,1  that  of  a 
man,  twenty-four  years  old,  who  from  exposure  became  affected  with 
headache  about  the  supra-orbital  region,  vertigo,  noises  in  the  ears, 
facial  neuralgia,  and  muscular  contractions.  At  the  end  of  a  year  he 
had  vomiting,  want  of  appetite,  general  debility,  and  a  continuation  of 
the  supra-orbital  headache.  There  were  also  amblyopia,  diplopia,  ex- 
ternal strabismus,  dilatation  of  the  pupils,  and  painful  contractions  of 
the  right  side  of  the  face.  The  pulse  was  full,  regular,  and  not  fre- 
quent; the  mind  was  unaffected.  Coma- supervened,  the  right  side  of  the 
face  became  insensible,  the  evacuations  were  involuntary,  speech  was 
impossible,  and  the  movements  of  the  tongue  were  imperfectly  per- 
formed. The  pulse  was  feeble  and  frequent,  and  death  ensued.  On 
post-mortem  examination,  a  reddish  serum  was  found  to  be  infiltrated 
between  the  convolutions.  At  the  base,  under  the  third  ventricle,  a 
gelatiniform  substance  enveloped  the  commissure  of  the  optic  nerves 
and  the  tuber  cinereum.  It  was  reddish  in  color,  and  was  closely  ad- 
herent to  the  pituitary  gland.  The  tubercula  mammillaria  were  sepa- 
rated by  a  reddish  mass,  which  extended  into  the  ventricle,  and  which 
there  had  the  size  and  form  of  a  nut. 

The  following  case,  cited  by  Gintrac a  from  Simon,  is  equally  inter- 
esting : 

"  A  woman,  thirty-five  years  old.  For  six  years  accessions  of  pain 
in  the  head.  Two  years  afterward  blindness  of  the  left  eye,  and  then 
for  two  months  the  most  intense  cephalalgia,  followed  by  loss  of  sight 
in  the  right  eye.  Pupils  still  active.  Anosmia,  although  the  pituitary 
membrane  preserved  its  tactile  sensibility.  Hearing,  touch,  and  taste 
unimpaired.  Skin  warm;  pulse  freqnent,  hard,  and  small.  Failure  of 
appetite;  thirst,  col stipation,  coma,  death. 

"  There  was  congestion  of  the  diplue  and  of  the  meninges.  The 
arachnoid  and  the  lateral  ventricles  contained  serum.  There  was  a 
grayish-white  deposit,  of  fibrinous  appearance,  in  the  pia  mater,  along 

1  Gazette  medicale  de  Lyons  et  moniteur  des  hopilaux,  1855,  p.  853. 

2  "Bulletin  de  la  soeiete  auutoiuique,"  1800,  p.  143. 


CHRONIC   CEREBRAL   MENINGITIS.  247 

the  course  of  the  middle  cerebral  vessels,  on  the  chiasma  of  the  optic 
nerves,  the  tubercula  mammillaria,  and  the  anterior  perforated  spaces. 
The  olfactory  and  optic  nerves  were  atrophied,  and  the  chiasma  was  de- 
formed. The  retime  were  normal.  The  tissue  of  the  brain  at  the  base 
was  superficially  softened." 

Treatment. — The  principles  which  have  been  laid  down  for  the  man- 
agement of  cases  of  chronic  verticalar  meningitis  are  equally  applicable 
to  the  basilar  form  of  the  disease.  The  iodide  of  potassium,  conjoined 
with  some  one  of  the  bromides,  should  be  administered;  and,  in  syphi- 
litic cases,  the  former  should  be  pushed  to  its  extreme  limit  by  gradu- 
ally increasing  the  doses.  At  the  same  time,  there  are  other  means  of 
treatment,  which  are  rendered  necessary  by  the  existence  of  paralysis, 
and  these  ordinarily  consist  of  strychnia  and  some  form  of  electricity. 
The  details  will,  perhaps,  be  more  clearly  shown  by  the  citation  of  a 
few  cases  from  my  note-book: 

A.  W.,  married,  aged  thirty-two,  consulted  me,  April  7,  1873,  for 
pain  in  the  head,  accompanied  by  paralysis  of  the  third  nerve  on  the 
left  side,  producing  ptosis,  external  strabismus,  dilatation  of  the  pupil, 
and  double  vision.  On  examination  with  the  ophthalmoscope,  both 
optic  papilhe  were  found  to  be  congested,  the  left  far  more  so,  how- 
ever, than  the  right.  He  had  had  an  epileptiform  convulsion  about 
two  weeks  before  coming  to  me,  and  had  suffered  very  often  from  at- 
tacks of  vertigo.  The  first  evidence  of  the  disease  was  the  cephalalgia, 
which  had  been  very  gradually  developed  during  six  or  seven  months, 
and  which  was  mainly  confined  to  the  left  temporal  region.  The  pa- 
ralysis of  the  third  nerve  had  been  suddenly  produced,  on  the  morning 
of  the  1st  of  April,  while  he  was  eating  his  breakfast. 

There  was  not  the  least  evidence  of  syphilis  in  this  case.  The  af- 
fection had  obviously  originated  from  long-continued  anxiety  of  mind, 
the  consequence  of  business  troubles. 

I  immediately  began  the  administration  of  the  iodide  of  potassium 
in  the  form  of  the  saturated  solution,  in  doses  of  ten  drops  three  times 
a  day,  increased  to  twelve  drops  the  second  day,  fourteen  the  third, 
and  so  on.  After  the  fourth  day,  the  intense  pain  in  the  head  began 
to  diminish;  and  on  the  tenth  day,  when  the  patienl  was  taking  thirty 
drops  e  [uivalenl  to  thirty  grains — three  times  daily,  it  entirely  disap- 
peared. The  paralysis  of  the  third  nerve,  however,  continued,  although 
'h'  doses  of  the  iodide  were  carried  up  to  over  two  hundred  grains 
daily,  or  seventy  grains  at  a  <\"Si\  The  medicine  was  then  discon- 
tinued, and  the  patient  was  treated  with  gradually -increasing  doses  of 
strychnia,  and  the  interrupted  primary  or  galvanic  currenl  applied  to 
the  closed  e\  •,  i,s  nearly  as  possible  over  the  internal  rectus  muscle 
on  the  upper  eyelid.  This  treatment  was  persevered  with  for  several 
weeks,  without  any  marked  e£E<  ol  upon  the  paralysis  of  th<   upper 

lid,  though    the    internal    rectus    muscle   gradually    recovered   it-  p0W6T, 


248  DISEASES   OF   THE   BRAIN. 

and  the  diplopia  disappeared.  Nearly  a  year  afterward,  when  I  again 
saw  the  patient,  the  lid  still  drooped;  but  there  had  been  no  return  of 
the  other  symptoms. 

A  gentleman,  aged  about  fifty,  single,  consulted  me  on  the  11th  of 
August,  1874,  for  intense  pain  in  the  right  side  of  the  head,  with 
which  he  had  suffered  for  several  months,  night  and  day.  Upon  exam- 
ination, I  discovered  that  he  had  experienced  an  attack  of  iritis  of  the 
left  eye  ten  years  previously,  and  that  there  was  other  evidence  of 
syphilis.  There  was  paralysis  of  the  internal  rectus  of  that  side,  which 
caused  strabismus,  though  no  diplopia,  as  the  sight  of  the  eye  had  been 
fast  by  extension  of  the  inflammation  to  the  capsule  of  the  lens,  causing 
opacity.  In  conversation  with  him,  I  observed  that  he  was  deaf  in  the 
right  ear,  a  fact  which  he  had  not  noticed  till  his  attention  was  called 
to  it  and  the  hearing  capacity  tested.  On  examining  the  ear  with  the 
speculum,  I  perceived  that  the  external  auditory  canal  was  closed  by  a 
growth  of  some  kind,  which  was  adherent  to  the  anterior  wall.  The 
ophthalmoscope  revealed  the  existence  of  marked  optic  neuritis  of  the 
right  eye,  and  the  patient  could  not  read  No.  3  of  Galezowski.  No  ex- 
amination could  be  made  of  the  left  eye. 

On  the  following  day,  when  he  made  his  visit  to  me,  the  right  side 
of  his  face  was  paralyzed,  as  was  also  the  right  side  of  the  tongue,  and 
his  speech  was,  in  consequence,  rendered  very  difficult  and  indistinct. 
I  then  began  the  administration  of  the  iodide  of  potassium,  in  the  form 
of  the  saturated  solution,  starting  with  the  dose  of  ten  drops  three 
times  a  day,  and  directing  it  to  be  gradually  increased.  This  was  con- 
tinued till  the  14th,  when  I  removed  the  growth  from  the  ear,  by  ex- 
cision, with  a  delicate  bistoury.  The  effect  of  this  operation  was  at 
once  evident,  so  far  as  the  hearing  was  concerned,  and  the  patient  de- 
clared that  the  pain  in  the  head  was  decidedly  mitigated.  As  it  still, 
however,  continued,  I  augmented  the  doses  of  the  iodide  by  six  drops  a 
day,  instead  of  three,  and  began  the  application  of  the  interrupted 
primary  current  to  the  paralyzed  muscles  of  the  face  and  tongue.  On 
the  20th  he  was  taking  twenty-one  grains  three  times  a  day.  The  pain 
was  decidedly  less;  but,  as  there  were  sharp  lancinating  pains  along  the 
course  of  the  auricular  branch  of  the  lesser  occipital  nerve,  I  made  an 
incision  through  the  scalp,  so  as  to  divide  it.  The  effect  was,  to  abolish 
this  pain  altogether.  The  intra-cranial  pain  gradually  diminished 
under  the  increasing  doses  of  the  iodide,  and  on  the  27th  of  August  had 
entirely  ceased.  The  medicine  was  continued  for  several  days  after- 
ward, and  was  then  omitted.  The  tongue  gradually  improved  in  motor 
power  ;  but  several  months  subsequently  was  not  protruded  straight, 
although  the  speech  was  as  good  as  ever.  There  has  been  no  return  of 
the  other  symptoms. 

The  growth  removed  from  the  ear  was  examined  microscopically  by 
my  friends  Prof.  Roosa  and  T.  E.  Clark,  as  well  as  by  myself,  and  we 


CHRONIC   CEREBRAL   MENINGITIS.  249 

agreed  in  the  opinion  that  it  was  neuromatous  in  character.  The  whole 
tumor  was  somewhat  larger  than  a  large  pea. 

The  following  very  interesting  case,  which  occurred  recently  in  my 
practice,  I  quote  from  Dr.  Lente's  excellent  paper  "  On  the  Neurotic 
Origin  of  Disease," '  read  before  the  New  York  Neurological  Society, 
December  7,  1874.  Dr.  Lente  had  frequent  opportunities  of  seeing 
this  patient  in  my  consulting-room,  and  of  witnessing  the  results  of  the 
treatment.  Mr.  W.  was  also  kind  enough  to  allow  me  to  present  him 
at  my  clinique  at  the  Medical  Department  of  the  University  of  New 
York,  and  to  describe  his  case  to  the  class  in  attendance. 

"  The  treatment  of  the  following  case  I  had  the  opportunity  of 
watching,  through  the  courtesy  of  Prof.  Hammond.  The  history  I  had 
from  the  patient  himself: 

"  Mr.  W.,  a  grain-inspector  of  Chicago,  was  attacked  three  years 
ago  with  epileptic  convulsions;  has  had  them  once  a  month  or  oftener; 
also  some  threatening  cerebral  symptoms;  had  no  treatment  that  he 
knows  of  except  moderate  doses  of  bromide  of  potassium  and  chloro- 
form inhalation.  In  June  last  he  had  a  recurrence  of  cerebral  symp- 
toms, insomnia,  pain,  double  vision,  etc.  This  lasted  two  weeks,  and 
disappeared.  On  the  14th  July,  after  some  exposure  to  the  sun,  he 
was  again  attacked  with  the  above  symptoms,  to  a  greater  degree,  and 
with  complete  inability  to  raise  the  eyeball  or  upper  eyelid  (left  eye), 
also  extreme  internal  strabismus,  diplopia,  and  severe  cephalalgia. 
These  symptoms  occurred  suddenly  in  the  night.  Could  neither  read, 
nor  distinguish  the  quality  of  grain.  The  strabismus  disappeared 
slowly,  and  the  ptosis  also  diminished  somewhat,  so  that  when  he  ap- 
plied to  Dr.  H.,  about  the  13th  of  October,  1874,  he  could,  by  an  effort, 
raise  the  lid  so  as  to  expose  the  cornea,  but  it  fell  back  immediately; 
other  symptoms  the  same.  He  was  put  upon  increasing  doses  of  the 
iodide  of  potassium,  with  the  idea  of  relieving  the  basilar  meningitis^ 
presumed  to  be  the  cause  of  the  symptoms,  the  application  of  the 
induced  current  to  the  brOW  and  temple,  and  the  hypodermic   injection 

of  strychnia.  No  iuiin<<!;<it<'  effect  could  be  expeoted  Erom  the  first  two 
remedies;  it  is  to  the  lasl  thai  1  desire  to  direct  attention.  Prof.  Ham- 
mond proposed  to  inject  the  solution  directly  into  the  affected  muscles, 
mid  accordingly  did  so,  using  gr.  ,'.  in  two  drops  of  water;  it  is  pre- 
sumed thai  it  passed  into  tin;  muscle,  or  most  likely  in  its  immediate 
proximity.  In  all,  six  injections,  I  think,  wen;  used.  I  watched  the 
effeel  cue  fully  and  tested  die  eye  a  ml  lid  after  each.  They  were  done 
each  alternate  day.  lie  deolared  thai  lie  peroeived  quite  a  decided  ef- 
feel.    Aiter  the  second  (here  was  no  doubt,  as  1  could  see  the  ohange 

within  fifteen  minutes,  both    Oil    the    hall    and    on    the  lid,  I  ially 

on  the  Latter;  after  th,.  third,  the  ptosis  had  entirely  disappeared,  and 

he  could  raise  the  ball  to  an  horizontal  plane;  the  diplopia  had  disap- 

1  PiychologicdL  and  if edico^Ltgal  Journal,  February,  1875  y.  82. 


230  DISEASES  OF  THE  BRAIN. 

pearcd,  and  ho  could  read  by  holding  the  book  low.  After  the  fifth  in- 
jection (gr.  -jV)  no  difference  in  the  appearance  of  the  eyes  was  distin- 
guishable, and  he  could  read  with  the  book  held  directly  before  him. 
He  considered  himself  cured." 

In  this  case  the  iodide  was  carried  to  doses  of  sixty  grains  three 
times  a  day,  before  the  pain  began  to  yield;  and  eighty  grains,  equal  to 
two  hundred  and  forty  grains  daily,  was  reached,  and  continued  for 
several  days,  before  it  was  deemed  advisable  to  omit  its  use. 

Mr.  B.  was  sent  to  me,  December  19,  1874,  by  Prof.  M.  A.  Fallen. 
At  the  time  he  was  suffering  from  agonizing  pain  in  the  left  side  of  the 
head,  paresis  of  the  whole  right  side  of  the  body,  except  the  face,  apha- 
sia, of  the  amnesic  variety  mainly,  although  the  power  to  coordinate  the 
muscles  of  articulation  was  greatly  impaired,  and  from  decided  mental 
disturbance,  characterized  by  the  existence  of  hallucinations  and  marked 
dementia.  The  sight  of  both  eyes  was  weakened,  and  examination  with 
the  ophthalmoscope  showed  the  existence  of  double  optic  neuritis. 
There  was  a  clear  history  of  syphilis. 

I  immediately  began  the  administration  of  the  iodide  of  potassium, 
in  ten-grain  doses,  three  times  a  day,  gradually  increased,  as  in  the  fore- 
going cases.  By  the  time  twenty-grain  doses  were  reached  the  pain  in 
the  head  had  disappeared,  the  speech  was  much  improved,  the  weakness 
of  the  right  side  had  diminished,  and  the  mind  was  altogether  stronger. 
The  iodide  was  continued  up  to  sixty-grain  doses,  and  then,  as  the 
patient  was  apparently  cured,  it  wTas  omitted,  and  he  resumed  his  duties 
as  cashier  in  a  bank. 

Two  months  afterward,  he  had  a  relapse  into  his  former  condition. 
The  accession  was  sudden.  He  awoke  in  the  morning  with  pain  in  the 
head,  weakness  of  the  right  side,  and  complete  loss  of  speech.  His 
aphasia  was  removed  by  a  single  application  of  the  galvanic  current 
from  ten  cells  to  the  tongue,  and  I  increased  the  use  of  the  iodide  as  be 
fore.    He  again  recovered  his  health.    He  is  now  (March  23d)  quite  well. 

It  would  be  very  easy  to  adduce  many  other  cases  from  my  private 
and  hospital  practice,  but  the  foregoing  are  sufficient  to  indicate  the 
main  principles  of  treatment  in  chronic  basilar  meningitis.  Occasion- 
ally, in  cases  of  syphilitic  origin,  in  which  the  infection  has  been  recent, 
it  may  be  advisable  to  administer  mercury  in  some  one  of  its  forms. 
The  bichloride,  in  the  dose  of  the  one-sixteenth  of  a  grain,  may  be  given 
with  each  dose  of  the  iodide  of  potassium,  or  the  biniodide  in  like 
doses,  in  the  form  of  pill.  Whether  the  affection  has  a  syphilitic  origin 
or  not,  antiphlogistic  measures,  as  they  are  called,  are  not  proper.  On 
the  contrary,  wine  and  highly-nutritious  food  are  frequently  productive 
of  amelioration. 

Should  insomnia  be  present,  some  one  of  the  bromides  should  be 
given,  in  doses  of  from  fifteen  to  thirty  grains,  three  times  a  day,  till  ita 
full  effect  be  produced. 


TUBERCULAR  CEREBRAL  MENINGITIS.  231 

It  may  be  stated  that  I  have  never  observed  any  ill  effects  follow 
the  administration  of  the  very  large  doses  of  the  iodide  of  potassium 
which  I  have  recommended.  Coryza  is  certainly  not  more  apt  to  occur 
than  with  the  small  doses,  nor  is  it  more  severe.  Gastric  irritation  can 
generally  be  prevented  by  diluting  each  dose  in  a  sufficient  quantity  of 
water.  A  dose  of  fifty  or  sixty  grains  should  never  be  taken  in  less 
than  half  a  tumbler  of  water. 

In  the  treatment  of  the  paralysis  which  often  remains,  even  after  all 
active  disease  within  the  cranium  has  disappeared,  electricity  is  almost 
indispensable;  and  I  am  entirely  satisfied  that  the  hypodermic  injection 
of  strychnia  into  the  paralyzed  muscle,  or  as  near  as  may  be  to  it,  is  a 
measure  of  the  utmost  importance.  The  good  effects  of  it  were  very 
clearly  seen  in  one  of  the  cases  cited. 


CHAPTER  X. 

TUBERCULAR    CEREBRAL    JfEyiyGIT/S. 

Inflammation'  of  the  membranes  of  the  brain,  attended  with  or  due 
to  a  deposit  of  miliary  tubercles,  was  for  many  years  considered  as  a 
disease  peculiar  to  infancy,  and  was  known  as  acute  hydrocephalus  be- 
fore its  morbid  anatomy  and  pathology  were  clearly  comprehended.  It 
is  now  well  understood  to  be  an  affection  to  which  adults  are  liable. 

By  some  authors,  especially  Robin  and  Bouchut,  it  is  regarded  as 
not  being  tubercular  in  character.  It  has  hence  occasionally  been 
termed  granular  meningitis.  Although  mentioned  by  the  ancient  medi- 
cal writers,  no  clear  and  systematic  description  of  tubercular  meningitis 
was  given  till  Whytt '  published  his  essay  on  the  subject  of  dropsy  of 
the  brain.  Since  that  time  it  has  received  the  attention  of  many  writers 
in  this  country,  Greal  Britain,  France,  and  Germany. 

Symptoms. — Whytt  defined  three  periods  of  the  disease,  which  he 
marked  by  the  state  of  the  pulse.      I  think  the  Bymptoma  may  be  prop- 
oily  I  in  four  1.  The  prodromati  .  '.'.  The  si 
of  excitement;  3.  The  stage  of  depression;  and  1.  The  stage  of  re 
rence. 

1.  Tin:  Pbodbom  \  i  [G  Stags. — This  period  may  be  altogether  want- 
ing, or  ma  Blightly  manifested  as  not  to  b  '.  Generally, 
however,  it  is  well  marked. 

If  the  child  be  sufficiently  advanced  Ln  years,  a  change  of  di 
is  among  the  firs!  symptoms  perceived.     Thus  th  beoomes  irri- 

1 "  Observation!  on  the  moat  Frequent  Form  of  the  Bydrocephalus  [nternna,  \i/.., 
the  Ventricle*  of  the  Brain.    Works  of  Bobert  Whytt,  edited  by  l\id  Son.' 
Edinburgh,  1768,  p,  726. 


252  DISEASES  OF  THE  BRAIN. 

table,  caresses  are  disregarded,  and  dislike  is  shown  for  those  amuse- 
ments which  formerly  gave  pleasure.  At  the  same  time  the  appetite 
disappears,  and  the  child  loses  flesh  rapidly.  This  latter  is  not  noticed 
about  the  face,  but  is  mainly  confined  to  the  abdomen  and  limbs.  The 
bowels  are  generally  obstinately  constipated,  but  occasionally  there  is 
diarrhoea.  Headache  is  not  often  complained  of ;  neither  is  vomiting  a 
common  symptom  of  this  period.  Fever  is  not  continuous,  although  it 
is  generally  present  at  irregular  times  of  the  day. 

The  prodromatic  stage  may  last  only  a  few  days,  or  may  be  pro- 
longed for  two  or  three  months. 

2.  The  Stage  of  Excitement. — This  period  is  ushered  in  by  obsti- 
nate vomiting,  which  is  present  in  many  cases,  even  though  no  food  be 
taken.  Intense  pain  in  the  head  is  a  coincident  symptom,  and  is  so 
severe  that  the  child  puts  his  hands  to  his  head  and  cries  out  or  awakes 
screaming.  Convulsions  may  also  occur.  They  do  not  differ  in  gen- 
eral appearance  from  the  ordinary  epileptic  paroxysms,  and  may  be  re- 
peated several  times. 

Very  early  in  this  stage  the  fever  becomes  more  persistent  than  in 
the  first  stage,  although  it  may  still  be  irregular.  The  pulse,  however, 
is  not  hard  and  resisting,  as  in  other  inflammatory  affections,  but  is  soft 
and  compressible. 

Trousseau '  has  called  attention  to  a  condition  of  the  skin  present  in 
tubercular  meningitis,  which  he  at  first  regarded  as  peculiar  to  this  dis- 
ease, but  which  subsequent  investigation  showed  was  likewise  found  in 
simple  meningitis,  in  typhoid  fever,  and  some  other  affections.  If  the 
finger-nail  be  passed  lightly  over  the  surface  of  the  abdomen  or  the 
thorax  so  as  to  trace  a  series  of  lines,  in  about  thirty  seconds  the  skin 
becomes  red — the  color  being  at  first  diffused,  but  very  soon  the  lines 
made  by  the  nail  are  indicated  by  a  still  redder  color,  which  persists  a 
long  time.  Trousseau  calls  this  appearance  the  "  cerebral  stain  "  (tacha 
ctrtbrale).  The  phenomenon  he  attributes  to  a  profound  modification 
in  the  vascularization  of  the  skin;  and,  although  it  is  not  to  be  regarded 
as  absolutely  pathognomonic,  it  is  a  sign  of  very  great  importance. 

The  intellectual  faculties  are  not  yet  affected  to  any  considerable 
extent,  but  the  changes  of  character  and  disposition,  and  indifference  to 
things  which  formerly  excited  interest,  are  still  well  marked. 

The  physical  strength,  though  lessened,  is  still  not  yet  so  far  re- 
duced as  to  oblige  the  patient  to  remain  in  bed. 

The  tongue  is  usually  coated  and  red  at  the  edges,  the  appetite 
diminished,  and  the  bowels  are  obstinately  constipated. 

The  temperature  of  the  body  is  elevated,  but  not  to  an  extreme  de- 
gree; the  thermometer  indicating  from  101°  to  103°  Fahr.  Sometimes 
there  are  distinct  remissions  in  the  violence  of  all  the  symptoms,  but  the 
disease  nevertheless  goes  on  to  its  full  development.  The  transmission 
1  Op.  cii.,  Le9on  lv.,  "  Fi&vre  Cer<!;brale." 


TUBERCULAR   CEREBRAL   MENINGITIS.  253 

from  the  second  to  the  thud  stage  is  often  marked  by  an  amelioration 
which  may  last  several  days. 

From  what  has  been  said,  it  will  be  seen  that  the  characteristic  phe- 
nomena of  this  stage  are  headache  and  vomiting.  Its  duration  varies 
from  seven  to  fourteen  days. 

3.  Stage  of  Depression. — The  pulse,  which  in  the  previous  stage 
was  sometimes  as  high  as  1-10,  and  sometimes  as  low  as  80,  now  becomes 
less  rapid  than  is  normal,  and  may  even  fall  below  50.  At  the  same 
time  the  beat  is  quick,  but  the  interval  between  the  pulsations  is  at 
times  so  great  that  the  observer  is,  as  Dance '  says,  fearful  that  the 
action  of  the  heart  has  stopped.  The  interval  between  the  pulsations  i3 
often  irregular,  and  this  may  be  regarded  as  a  sign  of  unfavorable  im- 
port. 

In  young  infants  there  is  a  reduction  in  the  temperature  of  the  body 
below  the  normal  standard,  which  lasts  throughout  the  whole  of  this 
period.  Roger  regarded  this  reduction,  preceded  as  it  is  by  a  higher 
temperature,  and  followed  during  the  succeeding  stage  by  another  ele- 
vation, as  pathognomonic  of  tubercular  meningitis. 

The  continued  excitement  of  the  previous  stage  is  replaced  in  this  by 
a  strong  tendency  to  somnolence,  which  alternates  with  a  rather  quiet 
delirium.  The  patient  lies  on  his  back,  with  the  eyes  fixed,  but  yet  not 
looking  at  any  object  with  attention.  Events  taking  place  around  him 
no  longer  attract  notice,  and,  though  when  addressed  in  a  loud  tone  he 
may  turn  his  gaze  toward  the  speaker,  it  is  very  evident  that  the  words 
convey  no  idea  to  his  mind. 

The  lingers  arc  kept  in  almost  continual  motion,  picking  up  threads 
and  other  small  objects  from  the  bedclothes,  and  occasionally  clutching 
at  imaginary  things.  Again,  the  fingers  are  alternately  opened  and 
shut  without  any  real  or  apparent  motive,  and  again  the  head  is  turned 
restlessly  from  side  to  side  of  the  pillow.  Convulsions  are  very  gener- 
ally present  from  time  to  time  during  this  stage,  and  may  be  so  fre- 
quently repeated  as  to  leave  scarcely  any  interval  between  the  seizures, 
Even  if  the  attacks  do  not  involve  the  body  generally,  the  eyes  scarcely 
ever  escape;  there  being  Btrabismus,  convulsive  movements  of  the 
pupils,  and  constant  motions  of  the  eyeballs.  The  facial  muscles  aro 
likewise  often  affected. 

In  the  intervals  of  wakefulness,  the  cephalalgia  continues,  and 
causes  the  peculiar  scream  which  is  so  characteristic  as  to  I  Lved 

the  name  of  the  "  bydroc  iphalio  cry."  li  is  a  s  lund  such  as  might  bo 
produced  by  mingled  emotions  of  terror  and  grief.  Although  probably 
excited  by  the  pain,  it  is  more  or  less  automatio,  and  is  no1  exactly  such 
a  cry  as  would  be  produced  by  unmixed  physical  Buffering,  li  is  ac 
oompanied,  however,  by  that  contraction  oi  the  muscles  o\'  the  face  in- 
dicative of  suffering. 

*  "Memoirc  ear  Phydrootphale,"  Archivn ghtfrale  <L*  miilc'.ne,  is30. 


254  DISEASES  OF  THE  BRAIN. 

The  paleness  of  the  countenance  continues,  but  at  times  there  is  a 
sudden  redness,  which  disappears  as  rapidly  as  it  comes. 

The  conjunctivas  are  generally  injected,  and  photophobia  is  present. 
M.  Bouchut,1  who  has  given  great  attention  to  the  subject  of  ophthal- 
moscopy in  diseases  of  the  nervous  system,  finds  peripapillary  con 
gestion,  dilatation  of  the  retinal  vessels,  and  deformation  of  the  papilla? 

There  is  often  a  general  hyperassthesia  of  the  skin,  for  which,  how- 
ever, anaesthesia  may  be  substituted.  When  this  latter  is  the  case  the 
conjunctiva?  participate,  and  inflammation  results. 

The  limbs  are  weak,  and,  should  the  patient  attempt  to  walk,  the 
gait  is  staggering.  The  speech  is  hesitating,  is  rarely  indulged  in  ex- 
cept in  response  to  questions,  and  then  with  the  least  possible  expendi- 
ture of  words. 

The  vomiting,  which  formed  so  prominent  a  symptom  of  the  previous 
stage,  has  ceased,  but  the  constipation  still  persists. 

The  respiration  is  irregular,  sometimes  being  rapid  and  sometimes 
slow.  Occasionally  there  are  deep  sighs,  followed  by  numerous  quick 
inspirations,  arid  again  the  respiratory  movements  may  be  so  slight  as 
scarcely  to  be  perceived.  This  variation  from  the  normal  action,  as 
well  as  the  irregularity  of  the  heart's  movements,  is  due  to  the  implica- 
tion of  the  pneumogastric  nerves  at  their  origins. 

This  stage  may  last  for  from  two  or  three  days  to  two  weeks. 

4.  Stage  of  Recurrence. — The  characteristic  phenomena  of  this 
stage  are  the  return  of  the  fever  and  the  increase  in  the  violence  of  the 
symptoms  indicative  of  cerebral  disturbance.  Before  its  onset  there 
may  be  a  period  of  nearly  complete  intermission,  so  that  the  impression 
may  be  formed  that  recovery  is  taking  place.  This  apparent  cessation 
of  the  morbid  action,  however,  only  serves,  with  the  experienced  ob- 
server, to  make  the  reappearance  of  the  symptoms  more  striking. 

Convulsions  are  more  frequent  and  violent  than  in  the  previous 
stage,  and  tonic  contractions  of  the  limbs  are  not  uncommon.  These 
contractions  are  more  generally  met  with  in  the  muscles  of  the  neck 
and  upper  extremities,  and  vary  from  time  to  time  in  their  intensity. 
The  head  is  thus  thrown  backward,  and,  as  the  morbid  action  frequently 
extends  to  the  muscles  of  the  back,  an  appearance  in  the  patient  not 
unlike  that  present  in  tetanus  is  produced. 

Paralysis  eventually  supervenes.  At  first  this  is  incomplete,  affect- 
ing only  a  single  limb  or  the  muscles  of  the  face,  but  it  extends,  and 
both  limbs  on  one  side,  or  an  arm  and  a  leg  of  opposite  sides,  become  in- 
volved. Voluntary  power  is  lost,  but  reflex  movements  can  be  excited 
by  pinching  or  tickling. 

The  delirium  acquires  increased  intensity,  and  alternates  with  the 
somnolence,  which  likewise  becomes  more  profound,  and  which  gradu- 

1  "  Du  diagnostic  des  maladies  du  systemc  norveux  par  l'ophthalmoscopie,"  Taris, 
1866,  p.  45,  ct  seq.     Plates  iv.,  v.,  vi.,  vii.,  viii.,  ix.,  and  xi.,  of  the  Atlaa. 


TUBERCULAR   CEREBRAL   MENINGITIS.  255 

ally  masks  all  the  other  symptoms,  till  at  last  the  coma  is  persistent 
and  general,  and  spinal  sensibility  is  lost. 

Before  death  the  pulse  rises  in  frequency,  a  cold  sweat  makes  its  ap- 
pearance, and  the  patient  dies  either  by  a  slow  process  of  asphyxia,  or 
in  convulsions. 

The  fact  that  tubercular  meningitis  is  not  confined  to  infants  is  now 
generally  admitted.  Dance  a  was  the  first  to  recognize  its  occurrence  in 
adults,  and  Gerhard,2  of  Philadelphia,  a  few  years  subsequently  reported 
several  cases.  Ledibuder 3  also  pointed  out  the  analogy  between  the 
tubercular  meningitis  of  infants  and  that  of  adults,  and  still  later  Val- 
leix 4  gave  the  weight  of  his  authority  to  the  same  effect. 

So  far  as  the  symptoms  are  concerned,  I  have  never  been  able  to 
perceive  any  essential  points  of  difference  between  the  tubercular  men- 
ingitis of  children  and  that  of  adults. 

The  affection  is,  of  course,  modified,  as  are  all  other  diseases,  by  the 
age  of  the  patient,  but,  when  allowance  is  made  for  this  factor,  the 
morbid  process  is  one  and  the  same  in  character.  In  adults,  however, 
it  generally  supervenes  in  the  course  of  tuberculosis  of  the  lungs, 
whereas  in  infants  it  is  ordinarily  a  primary  manifestation  of  the  tuber- 
cular diathesis. 

Causes. — Tubercular  meningitis  is  an  expression  of  a  general  state 
of  the  system.  To  enter  at  length  into  the  question  of  its  etiology 
would  necessarily  involve  a  discussion  of  the  cause  of  the  diathesis  to 
which  it  is  essentially  due.  Nevertheless,  there  are  a  number  of  deter- 
mining causes  that  may  be  appropriately  considered.  Age  is  an  im- 
portant factor  in  determining  the  accession  of  tubercular  meningitis. 
It  is  rare  during  the  first  year  of  infancy,  but  is  more  common  during 
the  period  extending  from  the  second  to  the  seventh  year  than  any 
other  time  of  life.  From  eight  to  ten  it  is  much  less  frequent,  and  from 
ten  to  fifteen  is  rarely  seen. 

In  adults  it  is  most  common  between  the  ages  of  seventeen  and 
thirty.  From  thirty  to  forty  it  is  rare,  and  after  forty  is  scarcely  ever 
met  with. 

Males  are  more  frequently  the  subjects  of  tubercular  meningitis  than 
females,  and  this  holds  good  for  all  ages  of  life. 

The  season  of  the  year  appears  to  exercise  no  influence. 

As  to  many  other  exciting  causes  alleged  by  authors,  such  as  blows, 
emotional  excitement,  and  previous  diseases,  nothing  very  definite  is 
known.  The  same  cannot,  however,  be  said  of  the  morbific  influence  of 
bad  air,  insufficient  food,  improper  clothing,  neglect  of  cleanliness,  and 
a  disregard  of  other  sanitary  requirements. 

1  Op.  cit.  s  American  Journal  of  the  Medical  Science*,  1834. 

8  "  Essai  but  L'affeotion  tuberculeuse  aigue  de  la  pie-mere,"  Paris,  1887. 
*  "  Dc  la  meuinglte  tuberculeuse  ohez  I'adult"     Archives  g&nlralea  de  mvdecin* 
1838. 


256  DISEASES   OF   THE   BRAIN. 

Diagnosis. — Tubercular  meningitis  is  liable  to  be  confounded  -with 
several  other  affections,  and  can  sometimes  only  be  distinguished  with 
difficulty. 

From  simple  meningitis  it  may  be  diagnosticated  by  the  facts  that 
the  onset  of  the  former  is  sudden,  while  the  latter  is  insidious  in  its  ap- 
proach, and  slow  in  the  development  of  its  symptoms;  the  one  goes  on 
steadily  through  its  course,  the  other  halts  and  remits;  in  the  one  the 
temperature  of  the  body  rises  several  degrees,  in  the  other  the  elevation 
is  scarcely  ever  more  than  two  degrees;  in  the  one  there  is  no  hereditary 
tendency,  while  in  the  other  inquiry  will  usually  reveal  the  existence  of 
hereditary  tubercular  predisposition. 

The  mental  symptoms  show  a  marked  difference.  In  simple  menin- 
gitis the  delirium  is  often  furious,  and  is  always  very  active;  in  the 
tubercular  form  of  the  disease  the  delirium  is  quiet,  and  alternates  with 
stupor. 

In  typhoid  fever  there  may  be  vomiting  and  headache,  but  the 
bowels  are  not  constipated,  and  there  is  tenderness  over  the  right  hypo- 
gastric region.  Moreover,  the  epistaxis,  the  eruption,  and  the  swelling 
of  the  spleen,  which  occur  in  typhoid  fever,  will  aid  in  making  the  diag- 
nosis more  certain. 

Worms  in  the  alimentary  canal  may  give  rise  to  a  set  of  symptoms 
very  similar  to  those  which  form  the  prodromata  of  tubercular  menin- 
gitis. As  Jaccoud  observes,  therefore,  it  is  well,  whenever  a  child  ex- 
hibits these  symptoms,  to  administer  one  or  two  doses  of  a  strong  ver- 
mifuge. 

A  peculiar  affection,  to  which  young  infants  are  liable,  may  be  mis- 
taken for  tubercular  meningitis.  It  was  first  described  by  Dr.  Gooch,1 
but  derived  its  name — " hydrocephaloid  disease" — from  Dr.  Marshall 
Hall.  I  have  already  alluded  to  this  disorder  under  the  head  of  cerebral 
anaemia.  In  it  the  child  is  irritable,  restless,  starting  at  every  noise, 
moving  in  sleep,  and  often  waking  screaming.  Vomiting  is  frequently 
present,  but  the  bowels  are  loose.  The  whole  appearance  of  the  child 
betokens  exhaustion,  and,  if  due  care  be  not  taken,  death  may  ensue. 
The  absence  of  constipation,  the  history  of  the  case,  and  the  depressed 
state  of  the  fontanelle,  if  this  be  yet  open,  will  suffice  to  render  the 
diagnosis  clear. 

Trousseau  considers  the  irregularity  of  the  respiration  the  most  im- 
portant sign  indicating  the  presence  of  tubercular  meningitis.  "  In  no 
other  disease,"  he  says,  "will  you  meet  with  this  singular  anomaly. 
You  will  not  observe  this  unequal  and  irregular  respiration  either  in  the 
essential  convulsions  of  infancy  or  in  typhoid  fever.  I  have  reason, 
then,  for  insisting  on  the  importance  of  the  symptoms." 

Prognosis. — There  is  not  much  to  say  under  this  head.     The  ordi- 

1  "  On  Some  Symptoms  in  Children  erroneously  attributed  to  Congestion  of  the  Brain." 
Gooch's  Essays,  New  Sydenham  Society,  1859,  p.  179. 


TUBERCULAR   CEREBRAL   MENINGITIS.  257 

nary  termination  of  the  disease  is  death.  I  have  never  seen  a  case  re- 
cover; and,  though  instances  with  a  favorable  result  have  been  reported, 
I  am  disposed  to  think  the  diagnosis  of  such  has  been  erroneous.  Drs. 
Meigs  and  Pepper,'  of  thirty-one  cases,  had  no  recovery,  though  they 
report  a  case  of  tuberculosis  of  the  meninges — not  tubercular  menin- 
gitis— in  which  recovery  appears  to  have  taken  place,  though  the  child 
died  a  year  or  two  afterward  with  dysentery. 

It  seems  contrary  to  reason  to  expect  a  radical  cure  in  a  disease  in 
which  the  cause  cannot  be  removed.  Do  what  we  will,  the  tubercular 
deposit  remains;  and,  as  Jaccoud  remarks,  the  reported  cases  of  recov- 
ery were  rather  instances  of  a  long  remission  in  the  intensity  of  the 
symptoms.  Seitz,2  in  his  recent  treatise,  asserts  that  the  time  when  cases 
of  acute  hydrocephalus  were  cured  has  gone  by,  and  that  former  ap- 
parent success  is  to  be  attributed  to  false  diagnosis.  He  declares  that 
he  has  never  witnessed  a  case  terminate  favorably. 

Morbid  Anatomy  and  Pathology. — A  question  arises  at  the  outset  of 

an  inquiry  relative  to  the  morbid  anatomy  of  tubercular  meningitis, 
which  refers  to  the  essential  character  of  the  disease;  and  that  is, 
whether  the  gray  semi-transparent  granulations  met  with  on  post- 
mortem examination  are  tubercles,  or  whether  they  are  an  entirely  dis- 
tinct morbid  product  ?  Valleix,  Killiet  and  Barthez,  Barrier,  Grisolle, 
Meigs  and  Pepper,  and  others,  regard  them  as  tubercles.  Grisolle  ex- 
presses himself  clearly  on  this  point.  "  We  have  no  doubt,"  he  says, 
"that  these  granulations  are  tubercles  in  a  rudimentary  state;  for  we 
have  many  times,  in  the  same  subject,  followed  the  morbid  product  in 
its  different  phases  of  evolution  from  the  amorphous  condition  to  the 
fully-developed  tubercle." 

( )n  the  other  hand,  Bouchut,  basing  his  conclusions  mainly  on  the 
microscopical  observations  of  Robin,  is  of  the  opinion  that  the  granula- 
tions are  formed:  1.  Of  fibro-plastic  elements,  consisting  of  free  nuclei 
and  fusiform  cells,  and  ovoid  cells.  The  nuclei  are  ovoid  or  spherical, 
and  generally  very  small,  not  exceeding  0.008  to  0.009  in.  in  diameter. 
)^.  Of  a  great  quantity  of  granular  amorphous  homogeneous  matter, 
which  keeps  tin'  other  elements  strongly  united.  3.  Of  a  few  vessels 
ami  fibres  of  connective  tissue.  Among  all  these  elements  the  tubercu- 
lar oorpusoles  of  micrographers  are  no1  to  be  found;  and.  therefore,  the 
ise  cannol  be  regarded  as  tubercular  in  character.  M.  ESmpis1  also 
com.  nils  thai  tip'  mi'-!  !  analysis  shows  that  the  gray  granula- 

tions an-  entirely  distinct    from  tubercle.      On  the  other  hand,  it    is 

alleged— and    I    am    disposed    t"   think  with  force — that    the  most  which 

the  investigations  of  M.  Robin  and  others  in  accord  with  him  show,  is, 

1  "  A  Practical  Treatise  ""  the  Diseases  of  Children,"  Philadelphia,  1  s  7 '  > .  p.  I5S, 
■ u Die  Meningitis  Tuberculosa  d  ten."    Berlin,  1875,  p.  377. 

•  "Truito  de  la  granulio,"  Paris,  1865. 

18 


258  DISEASES  OF  THE  BRAIN. 

that  there  is  no  special  characteristic  of  tubercle  which  will  enable  us  to 
declare  with  certainty  that  it  is  present,  and  that  it  does  not  possess  a 
structure  which  is  the  same  in  all  stages  of  its  development.  The  col- 
lateral evidence  goes  very  far  to  support  the  view  that  the  granulations 
are  tubercular  in  character. 

The  question  which  also  arises,  as  to  whether  the  inflammation  pre- 
cedes the  tubercular  deposit,  or  vice  versa,  is  generally  decided  in  favor 
of  the  prior  appearance  of  the  tubercles.  The  granulations  are  met  with 
in  the  course  of  the  vessels  of  the  pia  mater.  This  membrane  is  always 
more  or  less  inflamed,  and  is  thickened  by  the  infiltration  of  sanguine- 
ous, serous,  plastic,  or  purulent  exudations.  The  granular  or  tubercular 
matter  is  generally  deposited  at  the  base  of  the  brain,  and  in  this  position 
is  doubtless  the  cause  of  the  derangements  of  motility  which  constitute 
so  prominent  a  feature  of  the  disease.  Its  ordinary  seat  is  along  the 
course  of  the  middle  meningeal  artery  and  its  branches.  Sometimes, 
though  rarely,  it  is  found  on  the  convexity  of  the  brain. 

The  tissue  of  the  brain  is  not  generally  much  involved,  although  on 
section  the  red  points,  indicative  of  the  situation  of  blood-vessels,  are 
very  much  increased  in  number.  Occasionally  there  are  small  extrava- 
sations of  blood  found  in  the  gray  substance. 

The  ventricles  are  distended  by  serum,  and  this  is  sometimes  so  great 
in  quantity  as  to  cause  the  rupture  of  the  septum  lucidum.  The  liquid 
is  either  clear  and  limpid,  milky  from  the  presence  of  pus-globules,  or 
bloody  from  containing  red  corpuscles. 

The  morbid  anatomy  of  the  lungs  and  other  organs,  although  inter- 
esting in  the  present  connection,  need  not  be  dwelt  upon;  suffice  it  to 
say  that  tubercular  deposits  are  always  met  with  in  some  one  or  more 
of  the  viscera  and  especially  in  the  lungs. 

Treatment. — In  regard  to  a  disease  so  uniformly  fatal  as  tubercular 
meningitis,  there  is  not  much  to  say.  The  principal  advice  I  have  to 
give  is,  to  refrain  from  blisters,  antimonial  ointment,  leeches,  and  drastic 
purgatives,  which  have  no  other  effect  than  to  shorten  the  life  of  the 
patient,  and  to  make  his  existence  still  more  intolerable  than  it  is  made 
by  disease.  Iodide  of  potassium  does  less  harm,  but  I  have  never 
known  it  do  any  good.  Niemeyer,  however,  recommends  it,  and  many 
will  doubtless  continue  to  employ  it  on  his  authority.  Seitz,1  in  a  work 
of  nearly  four  hundred  pages,  treating  of  tubercular  meningitis  in 
adults,  devotes  less  than  two  pages  to  the  subject  of  treatment,  and 
speaks  rather  flippantly  of  all  supposed  remedial  measures. 

When  we  have  any  reason  to  suspect  an  hereditary  tendency  to 
tubercular  meningitis,  prophylactic  measures  may  be  used  with  hope  of 
success.  These  consist  in  providing  for  pure  air,  ample  clothing,  nutri- 
tious food,  and  in  the  administration  of  cod-liver  oil,  iron,  iodine,  and 

1  Op.  et  loc.  cit. 


SUPPURATIVE  ENCEPHALITIS  OR  CEREBRITIS.  259 

quinine.  A  climate  not  subject  to  sudden  vicissitudes,  and  of  such  a 
character  as  regards  warmth  and  dryness  that  the  patient  can  spend  a 
great  portion  of  the  day  in  the  open  air,  is  also  a  matter  of  prime  im- 
portance. 


CHAPTER  XI. 

SUPPURATIVE    ENCEPHALITIS    OR    CEREBRITIS. 

Suppurative  inflammation  of  the  brain  is  a  very  rare  affection  un- 
complicated with  meningitis.  In  this  latter  connection  it  has  already 
been  sufficiently  considered.  In  the  present  chapter,  therefore,  I  shall 
discuss  it  solely  as  an  independent  lesion,  and  mainly  in  reference  to  the 
subsequent  formation  of  abscess. 

Symptoms. — The  symptoms  of  suppurative  inflammation  of  the  brain 
vary  according  to  the  seat  of  the  lesion,  and  are  rarely  of  such  a  charac- 
ter as  to  enable  us  to  say,  with  any  great  degree  of  certainty,  that  we 
have  a  case  of  uncomplicated  encephalitis  before  us.  Nevertheless,  cer- 
tain phenomena  have  been  recognized,  and,  after  death,  the  evidences 
of  inflammation  of  the  brain  have  been  discovered.  But  these  symp- 
toms are,  many  of  them,  met  with  in  other  cerebral  disorders,  and  there- 
fore cannot  be  regarded  as  pathognomonic.  It  is  difficult,  if  not  impos- 
sible, to  arrange  them  in  stages;  and  therefore,  after  the  prodromata,  I 
shall  consider  the  phenomena  of  acute  encephalitis  in  accordance  with 
their  relation  to  the  several  functions  of  the  organism  liable  to  be 
affected. 

The  premonitory  symptoms  are  similar  to  those  of  cerebral  con- 
ion,  and  doubtless  depend  upon  a  like  pathological  condition.  Thus 
there  are  vertigo,  pain  in  the  head,  noises  in  the  ears,  troubles  of  vision, 
numbness,  and  difficulties  of  speech.  They  never,  however,  last  as  long 
as  they  do  in  simple  congestion. 

Sometimes  the  first-observed  symptom  of  approaching  encephalitis  is 
an  epileptiform  convulsion. 

In  the  fully-established  disease  the  phenomena  are  very  decided,  but 
at  the  same  time  have  no  necessary  or  constant  relation  with  the  pa- 
thology, as  similar  symptoms  are  met  with  in  oilier  very  dillerenl  all'ee- 
tions. 

/'  f  Sensibility,     At  first,  there  is  generally  hyperesthesia; 

subsequently,  anaesthesia.  Beadache  is  a  common  symptom,  as  it  Lb  in 
so  many  other  cerebral  diseases.  There  is  no  particular  location  of  the 
pain— sometimes  the  frontal  region,  at  others  the  occipital,  and  again 
the  vertical  or  parietal  regions,  being  its  seat.  It  varies,  likewise,  as 
regards  intensity  and  form,  and  may  consist  of  a  feeling  of  fullness  or 


260  DISEASES  OF  THE  BRAIN. 

constriction  only.  It  is  present  from  the  very  beginning  of  the  disease, 
and  usually  continues  through  its  whole  course. 

Pains  are  felt  in  various  parts  of  the  body,  are  sharp  and  lancinating, 
and  often  attended  with  cramps.  Cutaneous  hyperesthesia  is  also  oc- 
casionally met  with. 

In  the  next  place,  there  is  anesthesia,  with  all  its  accompaniments 
of  formication,  numbness,  and  other  abnormal  sensations  of  the  kind, 
mainly  affecting  the  face  and  upper  extremities.  As  to  the  special 
senses,  the  sight  is  almost  always  deranged.  There  are  bright  flashes  of 
light,  iridescent  appearances,  and  photophobia,  all  showing  increased 
irritability  of  the  retina.  The  pupils  are  contracted,  the  conjunctivae 
suffused,  and  the  eyeballs  are  the  seat  of  a  dull,  aching  pain.  Subse- 
quently, the  pupils  become  dilated,  and  vision  is  lost.  Ophthalmoscopic 
examination  shows,  in  the  early  stages,  papillary  infiltration,  with  retinal 
congestion,  and  later,  papillary  atrophy  and  granular  degeneration,  the 
results  of  optic  neuritis.  There  is  also,  generally,  double  vision,  to 
which  allusion  will  be  more  fully  made  directly. 

The  hearing  is  at  first  very  acute,  and  even  slight  noises  are  more  or 
less  painful.  Noises  in  the  ears,  of  various  kinds,  are  present.  As  the 
disease  advances,  the  hearing  becomes  much  impaired,  and  is  gradually 
lost,  in  one  or  both  ears. 

The  taste  and  smell  are  rarely  affected. 

Disorders  of  Motility. — As  with  the  sensibility,  the  motor  organs  of 
the  body  at  first  exhibit  evidences  of  increased  excitability.  Thus,  there 
are  twitchings  of  the  muscles,  mainly  of  those  of  the  face,  and  clonic  or 
tonic  spasms.  Sometimes  these  last  for  several  days.  Subsultus  is 
especially  noticed  in  the  flexor  tendons  of  the  wrist. 

General  convulsions  may  take  place,  with  or  without  loss  of  con- 
sciousness. Frequently  the  action  is  limited  to  one  side  of  the  body,  or 
implicates  one  side  of  the  face,  or  a  single  limb.  Strabismus  occurs, 
and  double  vision  is  produced,  at  this  stage,  from  spasms  of  one  of  the 
ocular  muscles. 

This  period  of  muscular  excitation  corresponds  very  accurately  with 
the  stage  of  augmented  sensibility. 

It  is  succeeded  by  a  period  of  diminished  motor  power.  Paralysis 
generally  begins  in  a  distant  part  of  the  body,  and  slowly  involves  one 
side.  Thus,  there  may  at  first  be  a  difficulty  in  raising  the  toes,  or  in 
grasping  things  with  the  fingers;  then  the  knee  becomes  weak,  the 
flexors  of  the  thigh  follow,  and  the  whole  limb  drags.  If  the  arm  be  the 
first  member  affected,  the  difficulty  advances  from  the  fingers  to  the 
elbow,  and  thence  to  the  shoulder.  Sometimes  the  morbid  action  ex- 
tends equally  on  both  sides  of  the  body,  and  then  the  gait  becomes 
weak  and  shuffling.  The  legs  are  spread  wide  apart,  so  as  to  increase 
the  base,  and  keep  the  centre  of  gravity  more  easily  within  it.  The 
knees  are  bent,  the  pelvis  is  flexed  on  the  thighs,  and  the  whole  body  is 


SUPPURATIVE   ENCEPHALITIS   OR   CEREBRITIS.  261 

inclined  forward.  The  face  rarely  escapes.  It  may  be  affected  on  one 
side  only,  in  which  case  there  is  distortion,  or  there  may  be  a  gradual 
failure  of  muscular  power  on  both  sides.  The  muscles  connected  with 
the  eyes  almost  alwaj's  suffer.  Ptosis  is  common,  and  external  strabis- 
mus, causing  double  vision,  accompanies  it,  both  being  produced  by  the 
implication  of  the  third  or  motor  oculi  nerve. 

One  side  of  the  face  sometimes  becomes  permanently  contracted, 
and  thus  an  appearance  is  produced  somewhat  resembling  that  which  is 
caused  by  paralysis  of  the  opposite  side.  It  may  be  distinguished  from 
this  latter  condition,  however,  by  the  fact  that  in  it  the  eyelids  are  spas- 
modically closed,  and  the  side  of  the  face  much  more  distorted  than 
when  there  is  paralysis  of  the  opposite  side.  The  tongue  is  always,  in 
my  experience,  prominently  affected.  The  first  sign  of  diminished  mo- 
tility is  the  frequency  with  which  it  is  bitten,  in  conversation  or  masti- 
cation, and  sometimes  it  is  made  quite  sore,  on  one  or  both  sides,  or  at 
the  tip,  from  this  cause.  Then  the  patient  discovers  that  long-continued 
speaking  causes  a  sensation  of  fatigue,  at  the  root  of  the  tongue,  and 
that  a  feeling  as  if  this  organ  were  too  large  for  the  mouth  is  expe- 
rienced. Then  articulation  becomes  indistinct,  the  words  are  clipped  or 
slurred  over,  so  that  at  times  it  is  difficult  for  others  to  understand  what 
he  says. 

Disorders  of  Intelligence. — The  first  indication  of  mental  weakness 
is  the  susceptibility  experienced  to  the  influence  of  emotions.  The 
patient  will  thus  get  uncontrollable  fits  of  laughing  or  crying  from  very 
slight  causes,  and  sometimes  from  no  apparent  cause.  These  paroxysms 
are  frequently  of  mixed  character,  the  patient  passing  from  laughing  to 
crying,  and  vice  versa. 

The  memory  begins  to  fail  at  a  very  early  period,  especially  as  re- 
gards the  names  cf  things.  The  enfeeblement  is  by  no  means,  however, 
confined  to  words,  but  facts  and  circumstances  likewise  fail  to  be  remem- 
bered. Gradually  a  condition  of  complete  dementia  ensues,  and  finally 
coma,  with  or  without  previous  or  alternating  delirium. 

Disorders  of  the  Functions  of  Organic  Life. — There  is  always 
febrile  excitement  in  encephalitis.  At  first  the  pulse  is  frequent,  rising 
to  120,  but  as  the  disease  advances  it  falls,  till  toward  the  close  it  goes 
below  the  normal  standard.  It  is  characterized,  according  to  lianas,1 
by  a  characteristic  tremulousness  (tremblottement),  which  he  oompares 
to  the  unequal  vibrations  of  a  cord  moderately  stretched.  This  pecu- 
liarity he  attributes  to  irregular  arterial  dilatation.  According  to  my 
rience,  the  symptom  is  by  no  means  constantly  mel  with,  and  it 
oertainly  is  uol  pathognomonic,  for  the  same  peculiarity  of  pulse  ia 
found  in  several  other  disorders.     In  a  oase,  however,  now  under  my 

can-,  in  uheh  th.  ,son   to  SUSpecl   61 ]>h;i litis  and  abscess,  the 

phenomenon   is  present  in  a  marked  degree,  nol  only  in  the  radial 
1  "Hull,  tin  de  la  soci6t6  m6dioale  d'&nulation,"  Jain  ot  Ootobre,  1828. 


262  DISEASES  OF  THE  BRAIN. 

artery,  but  in  the  temporal  and  the  angular,  as  it  passes  between  the 
nose  and  the  inner  angle  of  the  orbit. 

The  respiration  in  the  first  stages  is  not  materially  deranged,  but 
later  it  becomes  irregular  and  stertorous,  and  finally  asphyxia  may  take 
place. 

The  temperature  of  the  body  is  elevated  till  the  fever  abates,  and 
paralysis  makes  its  appearance.  The  thermometer  rarely,  however, 
goes  above  103°  Fahr.,  and  is  generally  a  degree  below  this  point. 

The  digestive  organs  usually  show  more  or  less  evidence  of  derange- 
ment. Constipation  is  always  a  prominent  feature,  and  the  appetite 
is  capricious.  At  times  the  patient  refuses  to  eat,  at  others  he  will 
cram  his  stomach  with  all  kinds  of  edibles.  Deglutition  is  often  troub- 
lesome, and  occasionally  dangerous,  from  paralysis  of  the  pharyngeal 
muscles.  Cases  are  on  record  in  which  death  has  occurred  by  the  food 
becoming  impacted  in  the  throat,  and  several  cases  have  come  under  my 
own  notice,  in  which,  from  a  like  cause,  a  fatal  result  was  barely  pre- 
vented by  the  use  of  very  energetic  measures. 

Moreover,  the  secretions  of  the  mouth  are  almost  always  altered 
either  in  quantity  or  quality,  or  both,  and  the  sensibility  of  the  tongue 
and  faucial  mucous  membrane  is  often  impaired.  Hence,  the  patient  is 
not  aware  that  he  has  filled  his  mouth,  and  goes  on  cramming  it  with 
food,  which  makes  an  alimentary  mass  larger  than  can  pass  through 
the  oesophagus.  This,  of  course,  even  without  the  pharyngeal  paralysis, 
interferes  with  the  act  of  swallowing.  The  faeces  are  sometimes  passed 
involuntarily,  but  this  is  almost  entirely  a  feature  of  the  last  stage. 
Nausea  and  vomiting  are  present  more  or  less  from  the  very  first. 

There  may  be  either  retention  of  urine  from  paralysis  of  the  bladder, 
or  incontinence  from  paralysis  of  the  sphincter.  Or  both  conditions 
may  coexist,  giving  rise  to  a  constant  dribbling. 

These  symptoms  may  be  arranged  in  five  classes,  designated  by  the 
most  prominent  feature  of  each:  the  paralytic,  the  comatose,  the  epi- 
leptiform, the  apoplectiform,  and  the  maniacal. 

Complications  may  and  often  do  arise.  Thus  there  may  be  menin- 
gitis, temporary  congestions,  extravasation  of  blood,  effusion  of  serum, 
or  some  intercurrent  visceral  affection. 

The  tendency  of  acute  encephalitis  is  to  suppuration  and  the  conse- 
quent formation  of  abscess,  and  many  of  the  symptoms  enumerated  are 
due  to  the  supervention  of  this  condition.  Death  ensues  gradually 
from  exhaustion  or  asphyxia,  or  may  take  place  suddenly  from  the 
bursting  of  the  abscess  into  the  ventricles,  or  upon  the  surface  of  the 
brain. 

Causes. — No  age  is  exempt  from  the  disease,  although  it  is  more 
common  in  old  persons  than  in  adults  of  middle  age  or  young  persons. 

It  is  probably  more  frequent  in  males  than  females  solely  from  the 
fact  that  they  are  more  subject  to  the  exciting  causes  of  the  disease. 


SUPPURATIVE  ENCEPHALITIS   OR   CEREBRITIS.  2G3 

Among  these  are  the  inordinate  use  of  alcoholic  liquors,  venereal  ex- 
cesses, extreme  intellectual  exertion,  great  emotional  disturbance,  and 
exposure  to  extreme  heat. 

It  may  also  be  induced  by  disease  of  the  internal  ear,  by  erysipelas 
affecting  the  head,  or  by  severe  attacks  of  scarlet  fever,  small-pox,  or 
other  eruptive  disease. 

The  most  common  cause,  however,  is  injury  of  the  brain. 

Diagnosis. — The  diagnosis  of  suppurative  encephalitis  is,  in  the  first 
stages,  difficult  if  not  impossible;  the  symptoms  being  common,  as  I 
have  already  said,  to  several  other  disorders.  From  cerebral  haemor- 
rhage the  distinction  can  be  made  without  difficulty,  for,  although  en- 
cephalitis may  be  developed  with  rapidity  and  by  an  apoplectic  seizure, 
the  tendency  is  for  the  subsequent  phenomena  to  become  progressively 
more  marked,  while  in  haemorrhage  there  is  a  gradual  amelioration. 
The  pulse  in  haemorrhage  is  from  the  first  slow  and  regular,  unless  the 
medulla  oblongata  be  the  seat,  while  in  encephalitis  it  is  rapid  and  ir- 
regular. 

Meningitis  is  always  associated  with  superficial  encephalitis,  and 
hence  the  symptoms  bear  a  certain  amount  of  resemblance  to  those  of 
the  affection  under  consideration.  But  the  latter  is,  in  general,  charac- 
terized by  the  facts  that  the  paralysis  is  more  defined,  both  in  intensity 
and  location;  that  the  delirium  is  less  acute;  that  the  cephalalgia  is  not 
so  intense,  nor  the  delirium  so  prominent  or  constant  a  phenomenon. 

In  epilepsy  the  paroxysm  is  the  main  phenomenon  of  the  disease. 
When  this  ceases,  the  patient  in  general  recovers  his  ordinary  mental 
faculties,  but  the  epileptiform  seizures  of  suppurative  encephalitis  are 
never  followed  by  complete  intellectual  restoration. 

The  disease  with  which  it  is  most  likely  to  be  confounded  is  that 
which,  from  its  obvious  characteristics,  is  denominated  general  paralysis. 
I  know  of  no  diagnostic  marks  between  the  two  conditions,  except  that 
general  paralysis  is  usually  of  longer  duration,  and  is  ordinarily  charac- 
terized by  a  peculiar  form  of  mental  aberration — the  dellre  des  gran- 
<!i  urs  of  the  French. 

The  symptoms  due  to  tumors  are  often  almost  identical  in  character 
with  those  attendant  on  abscess.  The  history  of  the  case  is  our  only 
guide.  The  fad  thai  the  brain  has  received  an  injury  of  some  kind 
will  indicate  suppurative  encephalitis  as  the  probable  difficulty.  A  lady 
is,  at  the  moment  <>('  writing  this,  under  my  oharge,  who  lias  been  suc- 
cessively tnadd  by  several  of  the  most  skillful  diagnostioians  <>f  this 
city,  at  times  for  absoess,  and  again  for  tumor,  and  I  venture  to  say  that 
no  one,  without  the  aid  of  a  post-mortem  examination,  can  say  winch 
lesion  e  i 

Prognosis.— Suppurative   encephalitis    is   invariably  fatal,  if   the   CUB- 

n ••(  terminate  in  resolution.     As  Jacooud,  however,  remarks, 
j  of  alleged  cure  before  the  Btage  of  suppuration  is  reached  must 


264  DISEASES  OF  THE  BRAIN. 

always  have  an  element  of  uncertainty  about  them,  and  do  not  there- 
fore permit  us  to  mitigate  the  unfavorable  character  of  the  prognosis. 
Drs.  Gull  and  Sutton,1  while  stating  that  there  is  nothing  in  the  morbid 
anatomy  of  cerebral  abscess  which  makes  it  necessarily  an  incurable 
affection,  admit  that  practically  it  is  irremediable.  In  this  opinion  I 
unhesitatingly  concur. 

Morbid  Anatomy  and  Pathology. — Suppurative  encephalitis  is  a  local 
disease  restricted  in  its  action,  and  hence  affecting  a  limited  and  well- 
defined  region  of  the  cerebral  tissue.  This  may  vary  from  the  size  of  a 
walnut  to  that  of  the  closed  fist,  and  is  ordinarily  irregularly  spherical 
in  shape.  Although  never  of  a  diffused  character,  there  may  be,  at  the 
same  time,  several  centres  of  inflammation.  The  part  most  frequently 
affected  is  the  gray  matter  of  the  cerebrum — the  morbid  process  in- 
volving the  white  substance  in  its  progress.  Next,  the  cerebellum  ap- 
pears to  be  a  favorite  seat.  The  corpora  striata,  and  the  optic  thalami, 
are  also  frequently  involved. 

It  sometimes  happens  that  the  pus  which  results  from  the  inflamma- 
tory action  is  not  collected  in  a  cavity,  but  is  infiltrated  into  the  sub- 
jacent tissue.  In  such  cases  there  is  no  well-defined  abscess,  but  a 
pulpy  mass  is  found  on  examination  after  death,  consisting  of  the  ele- 
ments of  the  brain-substance  in  a  more  or  less  disorganized  condition, 
with  those  of  the  blood  intermingled  with  pus — the  whole  of  a  greenish- 
yellow  color. 

Again,  there  may  be  a  collection  of  pus,  but  at  the  same  time  the 
walls  are  imperfectly  formed,  and  there  is  infiltration  to  some  extent. 
Lastly,  the  puriform  deposit  is  entirely  limited  by  a  membrane  consist- 
ing of  connective  tissue,  and  forming  a  cyst.  The  cerebral  substance  in 
contact  with  the  walls  of  an  abscess  gradually  breaks  down,  and  hence 
the  cavity  undergoes  constant  enlargement  in  all  directions,  but  espe- 
cially in  the  lines  of  least  resistance.  If  the  abscess  is  near  the  surface 
of  the  hemisphere,  the  tendency  is  to  enlarge  toward  the  external 
periphery  ;  if  it  is  situated  in  the  central  part,  in  the  corpora  striata  or 
optic  thalami,  the  absorption  of  the  peripheral  tissue  takes  place  in  the 
direction  of  the  ventricles.  In  the  first  instance,  when  the  rupture  en- 
sues, the  pus  will  be  extra vasated  into  the  cavity  of  the  arachnoid;  in 
the  second,  it  will  be  poured  out  into  the  ventricular  cavities.  In  either 
case,  coma  and  death  will  result  if  the  amount  of  pus  be  sufficiently 
large.  It  has  happened  that  the  pus'  has  escaped  from  the  cranium  by 
the  nose  or  ear.  A  lady  now  under  my  charge  experienced  this  result 
several  weeks  since;  a  large  quantity  of  purulent  matter  making  its 
exit  through  the  posterior  nares.  She  is  still  alive,  in  full  possession  of 
her  reasoning  faculties,  and  her  articulation  perfect,  but  with  the  loss 
of  sight  in  both  eyes,  paralysis  of  the  right  side  of  the  face,  the  left 
arm,  and  leg,  and  suffering  the  most  intense  and  constant  pain  in  her 
1  "  Abscess  of  the  Brain,"  Reynolds's  "  System  of  Medicine,"  vol.  ii!,  p.  544. 


SUPPUKATIVE  ENCEPHALITIS  OR  CEREBRITIS.  265 

head.  The  seat  of  the  lesion  is  probably  partly  in  the  right  half  of  the 
pons  Varolii.  The  suppurative  action  is  doubtless  still  going  on,  and  I 
regard  her  death  as  inevitable.1 

The  substance  of  the  brain  in  contiguity  with  the  abscess,  as  already 
stated,  undergoes  disintegration.     This  is  in  the  nature  of  softening. 

CHRONIC   CEREBRAL   ABSCESS. 

Suppurative  inflammation  of  the  brain,  terminating  in  the  formation 
of  abscess,  may  be  of  a  chronic  character,  the  course  of  the  disease  ex- 
tending over  several  months.  This  is  especially  apt  to  result  from  dis- 
ease of  the  internal  ear. 

Cases  have  been  reported  by  Abercrombie,2  Lallemand,3  Toynbee,* 
Ribiere,8  and  others,  and  three  have  come  under  my  own  observation. 

Chronic  abscess  may  also  result  from  injuries  of  the  brain  or  skull, 
and  from  suppuration  set  up  around  a  clot  due  to  extravasation  of 
blood. 

As  in  the  acute  form  of  the  disease,  there  are  no  very  characteristic 
symptoms  indicating  the  formation  of  abscess.  Indeed,  in  some  cases 
there  are  no  symptoms  at  all  referable  to  the  brain  for  the  whole  period 
of  the  course  of  the  disease,  till  a  short  time  before  death.  A  great 
part  of  a  lobe  may  be  destroyed,  and  even  both  anterior  lobes  almost 
entirely  obliterated,  and  the  patient  continue  to  manifest  his  ordinary 
degree  of  intelligence. 

Ribiere 6  has  collected  a  number  of  interesting  cases,  several  of 
which  almost  overturn  some  of  our  most  definite  ideas  of  cerebral  physi- 
ology and  pathology.  Thus,  he  cites  (Observation  II.)  the  case  of  a 
ni.iii  who  entered  the  II6pital  de  la  Pitie,  January  27,  18G6.  The  pa- 
tient  was  depressed,  answered  questions  with  difficulty,  and  complained 
of  a  violent  pain  in  the  head.  The  symptoms  were  supposed  to  indi- 
cate the  existence  of  typhoid  fever.  Two  days  subsequently  a  purulent 
discharge  was  noticed  from  the  right  ear,  and,  the  pain  in  the  head  per- 
sisting, the  diagnosis  was  changed  to  suppurative  otitis,  with  probable 
caries  of  the  petrous  portion  of  the  temporal  bone.  Leeches  were  ap- 
plied behind  the  ears  and  purgatives  administered,  after  which  the 

1  This  patient  died  Bhortly  after  the  foregoing  lines  were  written.   She  gradually  passed 

Into  a  state  <>t'  profound  coma,  In  which  Btate  death  occurred.    The  pus  continued  to  be 

discharged  in  small  quantity  ap  to  the  \n>t,  and  mi<  roscopecal  examination  disclosed  the 

ace  of  ganglion-cells  containing  granular  matter,  oil-globules,  and  other  remain-  of 

broken-down  nervous  tissue.    Mo  post-mortem  examination  could  he  obtained. 

4  "  On  Chronic  inflammation  of  the  Brain  and  its  Membranes,"  Edinburgh  Modioai 
aid  8urgiealJourtuu\  vol  itL,  1*1*,  p.  265,  </  tea, 

8  Op.  ft'/.,  p.  80,  rt  ft  q, 

4  "The  Diseases  of  the  Bar,"  etc.,  Philadelphia,  1860. 

5"I>.  l'encepliale  ennseculifs  a  la  carie  du  roelier."      These    de    I'iuR 

1  -'v..  •  Op.  at. 


266  DISEASES   OF   THE   BRAIN. 

patient  felt  so  far  well  that  he  determined  to  leave  the  hospital.  Ho 
went  to  work  again,  and,  on  the  12th  of  February,  attended  a  ball. 
The  following  morning,  pus,  mixed  with  blood,  was  discharged  from 
the  right  ear,  and,  the  tendency  to  stupor  reappearing,  he  again 
presented  himself  at  the  hospital.  It  was  then  ascertained  that  the 
flow  from  the  ear  had  begun  several  years  previously,  but  had  ceased 
for  the  two  years  immediately  preceding  his  first  entrance  into  the 
hospital. 

On  the  14th  he  was  in  a  state  of  not  very  intense  stupor,  since  he 
was  able  to  complain  of  the  pain  in  the  head;  his  pulse  was  60,  full  and 
hard,  and  pus  was  passing  from  the  right  auditory  canal.  By  the  16th 
of  February  the  stupor  had  increased.  There  was  no  paralysis,  devi- 
ation of  the  face,  nor  alterations  of  sensibility.  The  patient  under- 
stood questions  put  to  him,  but  answered  slowly  and  imperfectly.  The 
eyelids  were  closed,  light  appeared  to  be  unpleasant,  and  the  purulent 
flow  still  continued.  He  died  at  nine  o'clock  that  night,  without  con- 
vulsions. 

The  post-mortem  examination  of  the  head  revealed  the  following 
condition: 

The  external  auditory  canal  was  filled  with  desiccated  purulent  mat- 
ter; there  was  neither  abscess  nor  abnormal  redness  about  the  ear. 

The  superior  longitudinal  sinus  was  gorged  with  blood,  the  veins 
were  black  and  dilated;  the  brain  appeared  congested,  but  a  yellow 
tint  of  the  right  cerebral  lobe  was  noticed.  At  the  inferior  face  of  this 
lobe,  where  a  rupture  had  occurred  in  handling  the  brain,  a  quantity  of 
pus  estimated  at  one  hundred  grammes  (about  three  ounces)  flowed 
out.  This  was  of  a  greenish  color,  and  of  offensive  odor.  The  cavity 
left  was  about  the  size  of  a  hen's  egg,  and  was  bounded  by  red,  indu- 
rated, and  thick  walls.  The  pus,  which  during  life  had  flowed  from  the 
auditory  canal,  had  not  come  from  the  abscess,  but  from  the  carious 
petrous  portion  of  the  temporal  bone. 

Around  the  abscess  the  substance  of  the  brain  was  yellow  and  soft- 
ened. Three-fourths  of  the  middle  and  posterior  lobes  were  infiltrated 
with  pus  and  softened  in  texture.  The  capillaries  were  not  visible  to 
the  naked  eye;  the  convolutions  of  the  island  of  Reil  were  not  recog- 
nizable, and  the  neighboring  convolutions  were  not  now  distinct.  The 
corpus  striatum  of  the  right  side  was  healthy  in  its  anterior  fourth.  In 
the  rest  of  its  extent  it  was  softened.  The  optic  thalamus  was  also 
softened,  as  were  likewise  the  roots  of  the  optic  nerve.  We  see  that, 
in  this  case,  as  Ribiere  remarks,  a  considerable  abscess  had  destroyed,  in 
great  part,  the  corpus  striatum  and  optic  thalamus,  and  that,  neverthe- 
less, the  patient  had  been  able  to  work  till  within  a  few  days  of  his 
death,  and  was  so  slightly  paralyzed  as  to  be  able  to  attend  a  public 
ball.  Aside  from  a  certain  hebetude,  the  intellectual  faculties  were  not 
deranged. 


SUPPURATIVE   ENCEPHALITIS   OR   CEREBRITIS.  207 

Another  patient  observed  by  Ribi6re  presented  an  entire  absence 
of  cerebral  troubles,  no  paralysis,  no  contractions,  no  convulsions;  the 
sensibility  was  intact,  and  the  intelligence  was  active.  Nevertheless, 
there  was  a  degree  of  stupidity  expressed  in  the  countenance,  and  the 
expression  was  dull.  Still  there  is  almost  always  some  pain  in  the  head, 
which  may  be  irregular  as  regards  its  location  and  character,  or  may 
oe  confined  to  one  particular  spot. 

In  one  of  the  cases  under  my  observation,  there  was  very  acute  pain, 
almost  constant  nausea  or  vomiting,  a  strong  tendency  to  coma,  and 
hemiplegia  of  the  left  side,  coexisting  with  purulent  discharge  from  the 
right  ear.  The  patient,  who  had  a  short  time  previous  suffered  an  attack 
of  scarlet  fever  to  which  the  ear-trouble  was  due,  died  suddenly,  coma- 
tose, but  without  convulsion.  Examination  after  death  showed  the 
existence  of  caries  of  the  petrous  portion  of  the  temporal  bone,  and  an 
abscess  containing  about  two  ounces  of  pus  in  the  middle  lobe  of  the 
right  hemisphere.  The  right  corpus  striatum  was  softened  in  about 
half  of  its  extent. 

In  the  other  case  there  had  been  profuse  discharge  from  the  right 
ear  for  several  years,  unattended  by  any  cerebral  symptoms  except 
occasional  pain  and  headache,  which  were  supposed  by  the  family  to  be 
due  to  gastric  derangement,  and  for  which  no  medical  advice  was  ever 
asked.  One  morning  the  patient,  a  young  lady,  twenty  years  of  age, 
was  suddenly  roused  from  bed  by  an  alarm  of  fire.  In  her  hurry  to 
dress  herself,  and  in  the  confusion  of  the  moment,  she  struck  her  head 
against  the  edge  of  an  open  door.  She  immediately  felt  a  severe  pain 
in  the  head  and  cried  out,  but  almost  instantly  sank  down  to  the  floor 
in  a  stupor,  from  which  she  never  emerged,  death  ensuing  within  five 
hours.  On  removing  the  calvarium  a  large  extravasation  of  pus  was 
discovered  under  the  arachnoid,  covering  the  right  hemisphere,  and  it 
was  ascertained  that  an  abscess,  the  cavity  of  which  was  as  large  as  a 
small  orange,  had  occupied  the  middle  lobe,  and  had  burst  through  the 
convex  superior  surface  by  rupturing  the  cerebral  substance.  The 
petrous  portion  of  the  temporal  bone  of  that  side  was  carious,  and  com- 
municated by  several  very  small  openings  with  the  abscess. 

When  speaking  of  cerebral  haemorrhage,  I  have  referred  t<>  another 
case  in  which  there  was  abscess  of  the  cerebellum,  produced  by  injury 
of  the  skull.  In  this  instance  there  were  notable  symptoms,  vertigo, 
convulsions,  nausea,  vomiting,  and  violent  pain  in  the  back  of  the  head. 
At  first  there  was  no  paralysis,  but  the  patient  subsequently  became 
paraplegic,  and  died  in  convulsions.  Examination  after  death  disclosed 
an  abscess,  the  cavity  of  which  comprehended  nearly  the  whole  of  tin: 
left  lobe  of  the  cerebellum. 

Prof.  Etoosa,'  while  expressing  the  opinion  that  a  suppurative  pro- 

1  "  A  Practical  Treatise  on  hi  eaaei  of  the  Bar,  Including  the  Anatoxnj  of  the  Organ." 
N'.n  York,  William  Wood  A  Oo  ,  1878,0.  148, 


2C8  DISEASES  OF  THE  BRAIN. 

cess  of  the  ear  is  probably  necessary  for  the  production  of  an  abscesa 
of  the  brain,  reports  a  case  which  leads  him  to  suspect  that  there  may 
be  such  a  thing  as  a  chronic  cerebral  abscess  leading  to  disturbing  aural 
symptoms,  such  as  tinnitus  aurium,  and  pain  in  one  side  of  the  head, 
without  any  primary  aural  affection.  He  treated  a  gentleman,  of  about 
twenty-nine  years  of  age,  for  some  months  for  such  symptoms  as  have 
been  indicated,  and  when  he  died  a  cerebral  abscess  was  found.  He 
could  hear  the  watch  for  but  three  inches  from  the  left  ear,  which  was 
the  affected  one,  and  the  drum  membrane-was  sunken.  Prof.  Roosa 
supposed  the  case  to  be  one  of  chronic  proliferous  inflammation  of  the 
middle  ear.  The  patient  got  no  relief;  he  became  very  despondent  on 
account  of  his  tinnitus  aurium,  and  gave  up  his  business  and  died  at  Sag 
Harbor,  Long  Island,  of  malignant  pustule,  about  two  years  and  a  half 
after  Prof.  Roosa  first  saw  him,  and  three  years  and  a  half  after  his  first 
aural  symptoms. 

Dr.  George  A.  Sterling  made  a  post-mortem  examination,  and 
found  great  injection  of  the  pia  mater  over  the  petrous  portion  of  the 
temporal  bone,  and  an  abscess  about  the  size  of  a  ten-cent-piece  in  the 
brain-substance.  It  was  bounded  by  inflammatory  adhesions,  and  con- 
tained about  ten  drops  of  pus.  The  abscess  was  situated  on  the  left 
side,  in  the  superior  lobe,  one  inch  from  the  median  line,  and  two 
inches  from  the  coronal  suture.  In  this  case  there  had  never  been  a 
suppurative  inflammation  of  the  ear. 

The  fact  that  abscess  of  the  brain  may  occur  without  being  preceded 
or  accompanied  by  suppuration  of  the  ear  is  beyond  doubt. 

Although  recovery  from  chronic  abscess  of  the  brain  never  takes 
place,  yet  life  is  often  prolonged  for  several  years,  even  when  there  may 
be  marked  symptoms  of  cerebral  disorder.  And  when  death  occurs  it  is 
generally  suddenly,  with  or  without  obvious  exciting  cause. 

Treatment. — The  treatment  of  acute  suppurative  encephalitis  is  alto- 
gether palliative.  Symptoms,  such  as  pain,  vertigo,  and  vomiting,  may 
be  controlled  to  a  certain  extent.  I  have  derived  considerable  benefit 
from  the  extract  of  Indian  hemp,  given  in  conjunction  with  the  bromide 
of  potassium.  The  doses  of  Squires's  extract  may  range  from  half  a 
grain  to  two  grains  three  times  a  day,  with  from  thirty  to  forty  grains 
of  the  bromide,  either  of  potassium  or  sodium.  The  pain  and  irrita- 
bility of  the  nervous  system  are  greatly  lessened  by  these  remedies,  and 
thus  the  patient's  condition  rendered  more  tolerable. 

When  there  is  reason  to  suspect  a  syphilitic  origin,  mercury  and 
iodide  of  potassium  may  be  administered  theoretically  with  some  pros- 
pect of  success,  but  practically  with  very  little  benefit.  The  medicines 
should  be  given  in  frequently-repeated  doses — calomel  being  the  prefer- 
able mercurial — so  as  to  bring  the  system,  as  soon  as  possible,  under 
their  influence. 

Bloodletting,  local  and   general,  blisters,   tartar-emetic,    and  other 


SUPPURATIVE   ENCEPHALITIS   OR   CEREBRITIS.  269 

measures  calculated  to  depress  the  powers  of  the  system,  are  worse  than 

useless. 

In  suppurative  disease  of  the  internal  ear,  probably  due  to  caries  of 
the  petrous  portion  of  the  temporal  bone,  preventive  measures  against 
chronic  abscess  may  do  something.  Leeches  applied  to  the  mastoid  pro- 
cess, and  blisters  behind  the  ear,  are  indicated,  and  mercury  with  iodide 
of  potassium  will  afford  a  chance  of  a  beneficial  result.  The  solution  of 
the  bichloride  of  mercury  with  iodide  of  potassium  in  water  constitutes 
an  eligible  preparation.  The  flow  of  pus  should  be  facilitated,  and  the 
propriety  of  trephining  the  mastoid  cells  may  be  a  question  for  consid- 
eration. The  management  of  injuries,  with  a  view  to  preventing  abscess, 
is  to  be  conducted  upon  very  obvious  surgical  principles. 

Note. — Under  the  name  of  Cerebria  Dr.  Charles  Elam '  has  de- 
scribed an  affection  of  the  brain  which  he  defines  as  "  a  spontaneous, 
acute  general  inflammation  of  the  substance  of  the  brain  uncompli- 
cated with  meningitis."  Dr.  Elam  has,  in  my  opinion,  adduced  very 
strong  evidence  of  the  existence  of  such  a  disease,  but  I  am  not  quite 
sure  that  the  symptoms  and  morbid  anatomy  are  sufficiently  character- 
istic to  warrant  at  present  its  introduction  into  our  nosology  as  a  patho- 
logical entity.     He  says  : 

"It  is  a  disease  which  may,  perhaps,  occur  at  any  period  of  life, 
although  I  have  never  seen  it  before  eight  nor  after  thirty-six  years  of 
age.  It  is  certainly  much  more  frequent  between  ten  and  thirty  than 
at  any  other  ages.  It  is  uniform  in  its  commencement  as  its  termina- 
tion. It  begins  with  vomiting,  and  it  ends  with  death.  The  inter- 
mediate phenomena  are  not  very  striking,  and  the  duration  is  from 
thirty-six  hours  to  twelve  days.  It  differs  in  the  most  marked  manner 
from  the  forms  of  encephalitis  hitherto  described,  in  its  causation,  its 
mode  of  invasion,  its  progress,  and  its  morbid  anatomy." 

I  cite  the  following  case,  which  will  give  a  good  idea  of  the  affec- 
tion in  question  : 

"  H.  F.,  a  boy,  aged  ten,  previously  in  good  health,  vomited  once 
on  the  morning  of  June  10th.  In  the  evening  I  saw  him,  and  was  in- 
formed that  he  was  then  much  better.  He  had  complained  slightly  of 
headache  at  the  moment  of  vomiting,  but  there  was  little  or  no  remains 
of  the  pain  afterward.  He  was  not  in  bed,  and  seemed  very  much  in  his 
usual  state,  except  some  little  languor.  The  pulse  was  about  seventy, 
regular  and  moderate  in  tone.  The  tongue  was  Blightly  furred,  and 
the  bowels  not  quite  so  regular  as  in  ordinary.  He  denied  positively 
and  repeatedly  having  any  pain  in  tin'  head,  Or  feeling  ill  ill  any  way. 
I  could  detect  no  such  alteration  in  the  pupils,  nor  Buoh  modification 
in  any  visible  or  peroeptible  organ  or  function,  as  to  lead  me  to  suspect 

1  "On  Cerebria  and  other  Diseases  of  the  Brain,"  London,  1872,  p.  32. 


270  DISEASES  OF  THE  BRAIN. 

serious  disease.  My  prescriptions  were  little  more  than  formal  direc- 
tions as  to  diet  and  general  management. 

"For  reasons  unnecessary  to  mention,  I  called  at  the  house  the 
next  day,  about  11  A.  M.  The  mother  said,  in  answer  to  my  inquiries, 
that  her  son  must  be  better,  he  had  slept  so  well,  and  was,  in  fact, 
asleep  still.  This  at  once  excited  my  suspicions,  and,  going  up-stairs, 
I  found  the  boy  pulseless,  rather  cold,  and  unable  to  be  roused  to  any 
degree  of  consciousness.  From  this  condition  he  never  rallied,  and  he 
died  the  same  afternoon,  about  thirty-two  hours  after  the  vomiting. 

"  Post-mortem  Examination,  Thirty-Jive  Sours  after  Death. —  No 
trace  of  disease  in  the  stomach,  or  any  of  the  abdominal  or  thoracic 
organs.  Head. — The  sinuses  a  little  more  full  than  usual,  but  the 
membrane  showing  no  signs  whatever  of  disease.  There  was  no  effu- 
sion, except  to  a  very  trifling  amount  in  the  lateral  ventricles.  The 
brain-substance  alone  showed  marks  of  pathological  change,  being  very 
closely  dotted  with  red  spots  ;  the  gray  matter  was  darker  than  usual, 
and  the  white  matter  slightly  rosy.  The  texture  of  the  brain  seemed 
to  be  almost  normal,  neither  being  softer  nor  harder  than  the  average. 
There  was  no  microscopical  examination  made  of  any  part  of  the  brain; 
but  no  doubt  remained  on  the  mind  that  this  was  a  case  of  pure,  un- 
complicated, idiopathic  inflammation  of  the  brain-substance." 

In  another  case  "  the  whole  mass  of  the  brain  was  so  altered  in 
texture  by  inflammatory  action  that  it  could  not  support  its  own 
weight,  nor  hold  together.  No  sooner  was  it  removed  from  the  head, 
and  placed  on  a  dish,  than  it  gave  way,  falling  prone  together  and 
flattening  like  an  imperfectly-made  form  of  jelly.  The  commissures 
were  all  ruptured  by  the  weight  of  the  hemispheres.  The  white  mat- 
ter of  the  brain  was  throughout  soft,  and  pinkish  in  color.  On  cutting 
it,  it  smeared  the  knife  with  a  streaked  stain.  Microscopically  ex- 
amined there  was  no  pus,  but  an  abundance  of  exudation  corpuscles." 

My  reasons  for  somewhat  doubting  that  these  were  cases  of  "a 
special  cerebritis,  uncomplicated,  general,  and  idiopathic,"  are  :  That 
the  structural  changes  may  have  begun  long  before  they  were  evi- 
denced by  any  notable  symptoms,  and  hence  may  have  existed  for 
some  time  before  coming  under  Dr.  Elam's  notice,  and  that  the  con- 
dition discovered  after  death  may  have  resulted  from  occlusion  of  some 
one  or  more  of  the  cerebral  blood-vessels.  Nevertheless  I  am  inclined 
to  think  that  Dr.  Elam  has  made  out  his  case;  at  any  rate,  he  has  made 
a  very  interesting  and  important  contribution  to  cerebral  pathology. 


DIFFUSED   CEREBRAL   SCLEROSIS.  971 


CHAPTER  XII. 

DIFFUSED     CEREBRAL    SCLEROSIS. 

By  diffused  cerebral  sclerosis  is  to  be  understood  a  morbid  condition 
of  some  part  of  the  brain  characterized  by  induration  and  atrophy  of 
the  tissue,  and  not  distinctly  circumscribed  except  by  the  anatomical 
limits  of  the  region  affected. 

It  is  not  a  disease  which  can  be  recognized  with  any  great  degree  of 
certainty  or  even  of  probability  during  life.  It  is,  however,  a  well- 
marked  pathological  condition,  giving  rise  to  very  prominent  symptoms. 
Of  late  years  the  affection  has  not  been  much  noticed,  except  incident- 
ally, by  a  few  writers  of  special  treatises — though,  under  the  name  of 
"  induration  of  the  brain,"  it  received  considerable  attention  many 
years  ago. 

The  symptoms  by  which  it  is  characterized  are  by  no  means  peculiar 
to  it,  though,  when  taken  collectively,  they  give  us  some  reason  to  diag- 
nosticate sclerosis  as  their  cause.  A  number  of  cases  have  come  under 
my  observation  in  which  the  lesion  was  probably  diffused  cerebral  sclero- 
sis ;  but  I  have  never  had  the  opportunity  of  verifying  my  diagnosis  by 
post-mortem  examination.  The  remarks,  therefore,  which  I  shall  make 
on  the  morbid  anatomy  will  mainly  be  based  upon  the  studies  and  obser 
vations  of  other  writers. 

Symptoms. — The  symptoms  of  diffused  cerebral  sclerosis,  like  so  many 
other  brain-affections,  are  connected  with  the  mind,  with  sensibility,  and 
with  the  power  of  motion.  It  generally  makes  its  appearance  during 
infancy,  and  produces  an  arrest  of  development  in  the  part  of  the  brain 
affected,  and  consequently  in  certain  parts  of  the  body.  The  initial 
phenomena  are  those  of  congestion  and  inflammation,  during  the  course 
of  which  epileptic  convulsions  frequently  ensue.  These  may  be  few  in 
number,  and  may  cease  in  a  few  days,  or  they  may  be  very  frequently  re- 
peated  and  last  for  several  years,  or  during  the  whole  life  of  the  patient. 
The  mind  remains  undeveloped,  Bpeeoh,  if  already  acquired,  often  becomes 
imperfect,  and,  if  not  yet  present,  may  never  be  commenced.  The  limbs, 
usually  only  on  one  side  of  the  body,  become  paralyzed,  and  do  no1  grow 
with  the  same  rapidity  as  those  on  the  sound  side  Contractions  arc 
very  apt  to  take  place,  from  the  Eaot,  probably,  that  the  normal  degree 
of  antagonism  between  the  muscles  is  destroyed,  and  thai  those  uot  so 
much  paralyzed  as  others  draw  the  limbs  in  the  direction  of  their  ad  ion. 
It  is  quite  common,  therefore,  in  the  affection  under  consideration,  to 
find  the  angers  draw  d  into  the  palm  of  the  hand,  the  wrist  flexed  on  the 
forearm,  the  forearm  on  the  arm,  and  the  arm  drawn  backward  by  the 


272  DISEASES  OF  THE  BRAIN. 

action  mainly  of  the  latissimus  dorsi.  In  the  lower  limbs,  club-feet  are 
produced  in  a  similar  manner. 

It  is  not  uncommon,  too,  to  find  one  or  more  senses  weak  or  alto- 
gether lost,  and  the  general  sensibility  of  the  body  diminished  on  one 
side. 

The  urine  and  fasces  are  often  passed  involuntarily,  or  else  the  patient, 
from  never  having  acquired  a  sense  of  propriety  or  cleanliness,  passes 
them  whenever  he  chooses,  at  any  time  or  place. 

With  this  general  idea  of  the  symptoms,  I  proceed  to  refer  some- 
what at  length  to  its  histcry,  in  the  course  of  which  I  shall  quote  several 
cases  in  illustration  of  its  progress. 

The  first  to  direct  specific  attention  to  the  disease  under  consideration 
was  M.  Pinel,1  the  younger,  who,  in  a  memoir  read  before  the  French 
Academy  of  Sciences,  May  27,  1822,  brought  forward  several  cases  in 
illustration  of  what  he  denominated  "  induration  of  the  brain."  I  quote 
the  first  case  in  full  as  a  typical  example  of  the  affection: 

Beler,  aged  eighteen  years,  an  idiot  from  birth,  was  admitted  into 
the  Salpetriere  Hospital,  June  1,  1821.  The  patient  was  paralyzed  in  the 
left  arm  and  leg.  She  could  not  use  this  arm,  for  the  hand  was  strongly 
flexed  on  the  forearm,  and  could  not  be  extended.  She  walked  with 
great  difficulty,  dragging  the  left  leg.  Her  intellectual  faculties  were 
very  much  restricted  ;  she  comprehended  only  the  questions  which  were 
addressed  tc  her  relative  to  her  health,  her  intelligence  not  extending 
beyond  that  point.  She  had  also  great  difficulty  in  articulating  the 
words  yes  and  no,  which  were  the  only  words  she  could  speak.  She  had 
no  particular  habit,  was  always  calm  and  tranquil,  and  had  to  be  antici- 
pated in  all  her  wants.  She  was  subject  to  occasional  attacks  of  epi- 
lepsy ;  but,  when  the  paroxysms  came  on,  she  had  fits  almost  without 
intermission  for  thirty  or  forty  hours.  They  returned  about  every 
twenty-five  days.  On  the  4th  of  December,  1821,  the  patient  was  taken 
with  a  series  of  epileptic  fits,  almost  continual  in  character,  which  lasted 
during  four  days,  the  paroxysms  succeeding  each  other  with  inconceiv- 
able rapidity.  During  these  continuous  convulsions  the  right  limbs 
were  affected  with  violent  movements.  The  left  limbs,  which  had  been 
paralyzed  for  a  long  time,  were  also  strongly  agitated,  and  the  general 
sensibility  was  abolished.  The  face  was  red,  the  eyes  were  twisted,  the 
dejections  were  passed  involuntarily,  the  pulse  was  frequent  and  irreg- 
ular, and  the  respiration  unequal  and  jerking.  The  patient  died  on  the 
fourth  day,  without  there  having  been  any  remission  in  the  symptoms. 

Post-mortem  Examination. — "  General  marasmus  ;  remarkable  ema- 
ciation of  the  paralyzed  limbs.  The  cranium  was  thick,  ebu mated,  and 
rery  hard  to  break.  The  meninges  were  pale  and  healthy.  The  right 
lobe  [hemisphere]  of  the  brain  was  very  much  smaller  than  the  left,  it 

1  "  Recherches  d'anatomie  pathologique  sur  l'endurcissement  du  systeme  nervcux," 
Journal  de  Physiologic  de  Maycndie,  tome  ii.,  1822,  p.  191,  el  seq. 


DIFFUSED   CEREBRAL   SCLEROSIS.  273 

was  atrophied  ;  the  convolutions  were  almost  obliterated  and  very  small, 
especially  in  the  frontal  and  occipital  regions.  They  were  large  and 
deep  in  the  inferior  part.  The  cortical  substance  was  thicker  than  it 
generally  is ;  the  lateral  ventricle  was  very  small  and  dry.  The  sub- 
stance of  the  brain,  throughout  the  whole  extent  of  this  right  lobe 
[hemisphere],  and  notably  above  the  ventricle,  was  of  remarkable  hard- 
ness, and  it  was  torn  with  difficulty  by  the  fingers,  the  tissue  separating 
in  longitudinal  bands  which  converged  toward  the  corpus  striatum. 

"The  left  lobe  [hemisphere]  of  the  brain,  much  more  developed 
than  the  right,  was  of  the  softness  and  consistence  of  the  healthy  brain- 
tissue,  and  this  condition  made  the  alteration  in  the  right  lobe  [hemi- 
sphere] more  obvious." 

The  rest  of  the  description  refers  to  other  organs. 

In  regard  to  this  case,  M.  Pinel  remarks  that  to  the  pathological 
condition,  the  loss  of  the  power  of  motion  in  the  whole  of  one  side, 
the  almost  complete  annihilation  of  the  intellectual  faculties,  and  prob- 
ably the  epileptic  fits,  are  to  be  ascribed.  The  condition — which  is  fre- 
quent with  idiots,  but  of  which  it  is  often  difficult  to  estimate  all  the  va- 
rious symptoms — is  ordinarily  revealed  less  by  the  paralysis  of  the  limbs 
than  by  the  distortions  which  it  determines  in  the  feet  and  the  hands. 
Three  other  cases  are  adduced,  in  one  of  which  the  cerebellum  was  also 
in  part  indurated.  M.  Pinel,  as  the  result  of  his  observations  of  the 
morbid  anatomy,  states  that  the  nervous  tissue  resembles  a  compact  in- 
organic mass  ;  its  consistence  and  density  are  those  of  hard-boiled  white- 
of-egg ;  the  cerebral  substance  is  atrophied  ;  it  appears  entirely  de- 
prived of  blood-vessels — the  eye  perceiving  no  trace  of  capillaries.  The 
induration  appears  to  affect  more  particularly  the  medullary  sub- 
stance than  the  gray  substance;  it  was  never  observed  in  this  last-named 
tissue. 

Griesinger,1  under  the  name  of  "diffused  hypertrophy  of  the  con- 
nective tissue  of  the  brain,"  describes  the  affection  now  under  consid- 
eration, and  refers  to  an  interesting  case  reported  by  Isambert,'  in 
winch  a  microscopical  examination  of  the  altered  tissue  was  made.  It 
occurred  in  an  idiotic  child,  two  years  of  age.  The  ventricular  walls, 
the  great  ganglia,  the  pons  and  peduncles,  were  solid  and  hard  ;  their 
tissue  was  elastic,  like  caoutchouc  ;  the  nerve-tubes  in  the  white  sub- 
stance were  almost  completely  destroyed  and  an  amorphous  granular 
substance  occupied  their  place  ;  there  also  existed  newly-formed  fibrous 
connective  tissue.  In  regard  to  such  cases,  Griesinger  remarks  that, 
wlim  we  are  told  that  a  hitherto  healthy  and  well-developed  child,  about 
the  period  of  dentition,  or  during  the  second  or  third  year,  suddenly 
became  feverish,  was  attacked  with  convulsions  and  delirium,  Eel]  into 

1  "Die  Patbologie  and  Therapieder  paychlscheD  Krankheiten,"  Zweite  A  ullage,  1661, 
p.  301.    -Also  "New  Sydenham  Society  Translation,"  p. 

1  "Comptes  rendus  et  memoire  de  la  Soci6t6  dc  Biologic,"  tome  ii.,  1886,  p.  9. 

19 


274  DISEASES   OF  THE   BRAIN 

a  slightly  soporific  state,  and  soon  afterward  apparently  recovered,  but 
with  the  intellectual  and  physical  development  checked,  the  condition 
may  be  due  to  one  of  two  morbid  processes  :  either  there  are  slight  con- 
gestion and  inflammation  of  the  membranes,  or  there  is  encephalitis, 
which,  after  passing  out  of  the  acute  stage,  suspends  further  develop- 
ment in  the  affected  parts.  The  mind,  therefore,  ceases  to  expand  ; 
walking,  if  begun,  is  arrested ;  speech  remains  as  it  is,  or  is  altogether 
lost  ;  one  side  of  the  body  does  not  grow  so  fast  as  the  other  ;  and  con- 
vulsions, paralysis,  and  contractions,  are  present. 

A  case  in  point,  referred  to  by  Griesinger,  I  quote  from  Calmeil : ' 

"  M.  Alfred,  born  at  Havre,  single,  aged  twenty -two  years,  came  to 
the  Bicetre,  where  he  resided  twenty-two  months  :  he  had  been  an  in- 
valid since  infancy. 

"  Until  about  three  years  of  age,  he  had  exhibited  no  peculiarity  as 
regarded  intelligence — resembling  other  children  of  his  years. 

"  At  this  period,  however,  he  was  attacked  with  measles,  which  was 
considered  mild  in  form,  and  from  which  he  had  nearly  recovered,  when 
he  was  seized  with  a  succession  of  severe  eclamptic  paroxysms.  During 
twelve  hours,  it  was  impossible  to  rouse  him  from  the  coma,  and  gen- 
eral convulsions  were  present  almost  without  interruption. 

"  The  day  after,  it  was  perceived  that  he  was  deaf,  blind,  and  in- 
capable of  articulating  the  least  sound  ;  the  convulsions  had  ceased. 

"  At  the  end  of  fifteen  days  he  recovered  his  hearing  ;  after  a  year 
he  could  say  a  few  words  ;  but  the  retinae  continued  insensible  to  im- 
pressions of  light. 

"  It  was  now  perceived  that  he  walked  with  a  certain  degree  of  diffi- 
culty, and  that  he  could  hardly  use  the  right  hand.  At  times,  also,  he 
lost  consciousness,  but  without  falling,  and  it  was  subsequently  recog- 
nized that  these  attacks  were  epileptic. 

"  Until  the  age  of  thirteen,  the  intelligence  of  M.  Alfred  underwent 
scarcely  any  development,  and  he  remained  imbecile  notwithstanding  all 
the  efforts  made  for  his  improvement.  He  nevertheless  acquired  a  knowl- 
edge of  a  certain  number  of  words,  and  he  could  make  himself  under- 
stood whenever  he  had  a  want  to  gratify. 

"  At  the  age  of  nineteen  he  presented  the  symptoms  of  an  almost 
complete  state  of  idiocy.  He  comprehended  some  things,  and  could 
imperfectly  articulate  a  few  words.  He  was  not  evilly  disposed,  but  he 
was  incapable  of  attending  to  his  person,  and  even  of  eating  without 
assistance. 

"  He  could  take  a  few  steps  by  supporting  himself  against  the  wall, 
on  articles  of  furniture,  or  a  cane,  but  he  dragged  his  feet  on  the  ground, 
and  his  right  leg  appeared  to  be  weaker  than  the  left.  The  right  arm 
was  contracted  and  almost  immovable.  Tactile  sensibility  was  not  af- 
fected, anywhere.     He  did  not  appear  to  perceive  objects  placed  imme- 

1  "Traite  des  maladies  inflammatoires  du  cerveau,"  Paris,  1859,  tome  ii.,  p.  411. 


DIFFUSED   CEREBRAL   SCLEROSIS.  275 

diately  before  his  eyes,  and  the  pupils  were  dilated  and  insensible  to  the 
sudden  accession  of  light.  As  regarded  the  bladder  and  rectum,  he 
evacuated  them  without  seeming  to  exercise  the  least  restraint  of  clean- 
liness or  propriety. 

"  The  epileptic  paroxysms  occurred  with  long  intervals  between 
them,  and  presented  no  characteristics  worthy  of  special  mention.  The 
complexion  was  pale,  and  the  body  emaciated  and  notably  weak. 

"During  the  month  of  January,  1827,  there  was  frequent  cough, 
combined  with  abundant  expectoration,  diarrhoea,  and  other  symptoms 
of  phthisis."     He  died  in  February  of  the  same  year. 

Autopsy. — The  whole  of  the  right  side  of  the  body  was  much  less 
developed  than  the  left  side.  The  right  arm  and  leg  were  especially 
emaciated  and  thin.  "  The  face  was  free  from  distortion,  and  the  cra- 
nium, without  being  deformed,  was  small  and  very  narrow.  The  greater 
part  of  the  cranium  was  abnormally  thick,  and  contained  an  excessive 
amount  of  calcareous  matter. 

"  The  dura  mater  was  without  change,  and  did  not  adhere  to  the 
osseous  surfaces. 

"A  very  considerable  quantity  of  serum  was  infiltrated  into  the 
meshes  of  the  pia  mater — principally  toward  the  middle  and  convex 
surface  of  the  two  cerebral  hemispheres.  The  pia  mater  was  thickened, 
but  was  not  adherent  to  the  convolutions. 

"  The  left  cerebral  hemisphere  was  notably  smaller  than  the  right  ; 
the  posterior  lobe  being  particularly  remarkable  for  its  diminution. 
The  convolutions  were  flattened,  and  were  as  thin  as  the  blade  of  a 
knife,  were  resistant  to  the  touch,  and  were  of  a  clear  yellow  color. 
The  middle  and  anterior  lobes  were  neither  of  them  of  ordinary  size. 

"  The  posterior  lobe  of  the  right  hemisphere  was  less  developed  than 
in  a  healthy  brain,  but  the  number  of  atrophied  convolutions  was  small. 

"  On  cutting  into  the  left  posterior  lobe  with  a  bistoury,  its  tissue 
was  found  to  be  white,  compact,  homogeneous,  and  very  resistant.  It 
might  be  said  that  the  cerebral  substance  had  become  doughy,  and  that 
an  element,  foreign  to  its  nature,  gave  it  an  excessive  degree  of  hardness. 

"On  the  right,  the  atrophied  convolutions  of  the  posterior  lobes 
were  dilTicult  to  cut ;  their  structure  was  oompaot,  but  the  induration  of 
the  nervous  tissue  did  not  extend  deeply  into  the  thickness  of  the  1 

"  In  all  other  parts  of  tin-  lira  in  the  white  and  the   gray  Bubstai 
well  on  tin-  left  as  on  the  right  side,  were  apparently,  in  all  respects,  in  a 
Healthy  condition. 

"The  corpora  striata  and  the  optic  thalaini  wnv  free  from  change, 
cither  as  regarded  their  volume  or  their  structure. 

"Tie-  pons  Varolii,  the  tuberoula  quadrigemina,  and  the  peduncles 
of  the  cerebrum,  and  cerebellum,  were  in  a  normal  state. 

"The  Bpinal  oord  relatively,  and  perhaps  even  absolutely,  apj 
lo  be  larger  than  was  natural. 


276  DISEASES   OF  THE   BRAIN. 

"  The  optic  nerves  were  atrophied,  of  a  glossy  white  color,  and  very 
hard." 

Other  cases,  similar  in  general  features,  are  adduced  by  Calmeil. 

In  the  very  interesting  monograph  of  Cotard,1  to  which  reference 
has  already  been  made,  the  relation  of  sclerosis  to  atrophy  of  the  brain 
is  clearly  pointed  out.  As  indicating  a  certain  set  of  symptoms,  in 
existence  with  a  definite  pathological  state,  I  quote  the  following  case, 
No.  XXIX.  of  his  series. 

"  C,  aged  fifty-eight  years,  an  inmate  of  the  Salpetriere  since  1828, 
entered  the  infirmary  on  the  25th  of  April,  18G5,  under  the  charge  of 
M.  Charcot. 

"  She  gave  the  following  information,  which  she  said  she  had  from 
her  mother,  and  from  other  persons  who  had  brought  her  up  :  At  the 
age  of  eighteen  months  she  had  three  attacks  of  convulsions,  which  left 
her  paralyzed  on  her  right  side.  She  had  never  had  convulsions  since. 
She  had  already  begun  to  walk  when  the  seizures  took  place,  but  she 
did  not  walk  again  till  she  was  three  years  old. 

"  According  to  the  information  given  by  the  superintendent  of  her 
ward,  who  had  known  her  since  her  entrance  into  the  hospital,  her  intelli- 
gence had  always  been  weak;  she  was  incapable  of  attending  to  herself; 
she  could  read  tolerably  well,  and  could  sign  her  name  ;  she  had  always 
spoken  without  difficulty. 

"  She  had  been  employed  with  coarse  sewing,  and  had  invariably 
been  docile  and  attached  to  those  who  took  care  of  her. 

"  Her  health  had  always  been  good,  though  she  had,  when  about  the 
age  of  twenty-five  or  thirty,  several  attacks  of  hysteria.  Menstruation 
had  been  regular,  and  had  ceased  when  she  was  forty-five. 

"  For  about  a  year  the  patient  had  been  the  subject  of  frequent  at- 
tacks of  vomiting,  or  of  epigastric  pain.  At  the  time  of  her  admission 
to  the  infirmary,  she  was  very  much  emaciated  and  very  cachectic. 

"  Her  intelligence  did  not  appear  to  have  been  recently  enfeebled  ; 
she  could  read,  sign  her  name,  and  speak  without  difficulty. 

"  Her  senses  seemed  to  be  intact  ;  sight  was  good  in  both  eyes,  and 
the  pupils  were  equal.  There  was  no  facial  paralysis,  and  the  tongue 
was  protruded  straight. 

"  The  right  arm  was  emaciated,  atrophied,  and  contracted  ;  the  fore- 
arm was  pronated  and  semi-flexed  on  the  arm  ;  the  hand  was  flexed  on 
the  forearm,  and  inclined  toward  the  ulnar  side  ;  the  fingers  were  flexed 
in  the  palm  of  the  hand,  particularly  the  ring  and  little  fingers  ;  the 
index-finger  was  semi-flexed,  and  the  thumb  was  extended. 

"  It  was  possible,  without  very  great  force,  to  bring  the  several  parts 

of  the  limb  almost  into  a  state  of  extension,  but,  as  soon  as  it  was  left 

to  itself,  it  resumed  its  habitual  position.     The  patient  could  execute  a 

few  movements  with  the  shoulder  and  the  elbow,  but  the  wrist  was  ab- 

1  "£tude  sur  l'atrophie  partielle  du  cerveau,"  Paris,  18G8,  p.  49. 


DIFFUSED  CEREBRAL  SCLEROSIS.  277 

solutely  paralyzed,  and  the  fingers  could  only  be  moved  to  a  very  lim- 
ited extent. 

"  The  right  leg  was  less  atrophied,  and  there  was  no  other  deformity 
than  a  talipes  equinus.     The  patient  walked  with  a  cane. 

"  The  sensibility  of  the  right  side  was  intact,  and  no  very  notable 
difference  of  temperature  was  observed  between  the  healthy  and  the 
paralyzed  sides. 

"The  patient  died  May  17th,  after  symptoms  of  acute  peritonitis. 

"  Autopsy. — Cancer  of  the  stomach,  circumjacent  abscess,  purulent 
peritonitis. 

"No  exterior  deformation  of  the  cranium;  on  the  left  side  its  walls 
were  thick,  doubly  and  triply  so  at  some  points  ;  the  frontal  sinus  ex- 
tended to  the  left  of  the  mesial  line,  and  communicated  with  a  large 
cavity  situated  in  the  orbital  arch,  which  was  composed  of  two  thin 
osseous  lamella?. 

"  The  left  middle  fossa  was  smaller  than  the  right,  and  the  right 
cerebellar  fossa  was  smaller  than  the  left. 

"  The  dura  mater  being  incised,  a  large  quantity  of  serum  escaped 
from  the  left  side.  The  left  hemisphere  was  very  small,  shriveled,  and 
in  length  and  breadth  scarcely  two-thirds  the  corresponding  dimensions 
of  the  right  hemisphere.  The  convolutions  were  pressed  together,  were 
hard,  and  of  a  whitish  color. 

"  On  the  external  face  of  the  middle  lobe,  behind  the  posterior  mar- 
ginal convolution,  and  on  the  prolongation  of  the  fissure  of  Sylvius, 
there  was  a  deep  depression  running  upward  and  backward,  and  three 
or  four  centimetres  in  length.  At  the  bottom  of  this  depression  the 
convolutions  were  reduced  to  little  ridges,  which  were  hard,  and  of  a 
yellow  color. 

"  The  ventricle  was  considerably  dilated  ;  the  corpus  striatum  did 
not  appear  to  be  perceptibly  diminished  in  volume,  but  the  optic  thala- 
mus was  hardly  one-fourth  as  large  as  that  of  the  opposite  side. 
There  was  considerable  atrophy  of  the  left  crura  of  the  fornix,  and  of 
the  mammary  tubercle. 

"The  olfactory  and  optic  nerves  of  the  left  side  wore  apparently 
healthy  ;  the  tubercular  quadrigemina  were  not  atrophied. 

"  The  right  hemisphere  was  healthy. 

"  The  right  hemisphere  of  the  cerebellum  and  the  middle  cerebellar 
peduncle  of  the  same  side  were  atrophied." 

Examined  with  the  microscope,  the  indurated  convolutions  of  the 
left  hemisphere  presented  an  enormous  quantity  of  amyloid  corpu 
and  of  nuclei  of  connective  tissue  ■ 

The  following  eases  I  seleot  from  others  of  similar  oharaoter  which 
have  occurred  in  my  own  practice  : 

Case  L — .1.  S.,  a  boy,  aged  five  ye.-irs,  was  brought  to  me  in  the 
autumn  of  1869,  to  be  treated  For  epilepsy.     The  paroxysms  occurred 


278  DISEASES   OF   THE   BRAIN. 

several  times  a  day,  and  had  originated  when  the  child  was  two  years  of 
age,  in  consequence,  as  the  mother  thought,  of  a  fall. 

At  that  time  he  could  say  a  number  of  words,  and  was  rapidly  learn- 
ing to  talk  ;  his  intelligence  was  good,  and  he  had  been  walking  for 
several  months. 

But  after  the  first  convulsion  he  ceased  to  speak  and  to  walk,  though 
he  continued  up  to  the  time  I  first  saw  him  to  give  his  attention  to  very 
striking  objects,  such  as  noisy  tops,  bright-colored  articles,  and,  above 
all,  music  and  soldiers.  During  this  period  he  had  at  least  six  exacer- 
bations, characterized  by  pain  in  the  head,  repeated  convulsions,  and 
coma. 

When  he  was  about  two  years  and  a  half  old  it  was  observed  that 
he  did  not  move  the  left  arm  and  leg  so  freely  as  the  right,  and  soon 
afterward  he  ceased  to  move  them  at  all.  The  toes  then  began  to  be 
drawn  under  the  sole  of  the  foot,  and  the  heel  was  raised.  Then  the 
leg  became  flexed  on  the  thigh,  and  soon  afterward  the  fingers  of  the 
left  hand  and  thumb  were  gradually  bent  so  as  to  press  strongly  against 
the  palm.  The  wrist  followed,  and  then  the  forearm.  Both  limbs  were 
greatly  atrophied. 

When  he.  came  under  my  examination  he  was  having  epileptic  con- 
vulsions, both  of  the  grand  and  petit  mat,  every  day.  There  was  no 
deformity  of  the  skull,  though  it  was  certainly  small  for  his  age.  His 
mind  was  feeble,  and  he  did  not  give  attention  to  any  remarks  made  to 
him,  but  bright  objects  at  once  attracted  his  gaze,  and  he  made  efforts 
to  get  hold  of  them. 

I  examined  the  fundus  of  the  eyes  with  the  ophthalmoscope,  and 
discovered  an  anaemic  condition  of  the  retinae  and  atrophy  of  both 
optic  disks. 

I  gave  it  as  my  opinion  that  the  child  was  suffering  from  diffused 
cerebral  sclerosis,  involving  the  left  hemisphere  ;  and  that  there  was 
scarcely  any  prospect  of  material  amelioration  in  his  mental  or  physical 
condition. 

Case  II. — A  female,  aged  eight  years,  entered  the  New  York  State 
Hospital  for  Diseases  of  the  Nervous  System,  June,  1870,  having  pre- 
viously been  a  patient  at  my  clinic  at  the  Bellevue  Hospital  Medical 
College.  When  quite  an  infant  she  had  suffered  from  epileptiform  con- 
vulsions, which  had  been  almost  immediately  followed  by  paralysis  of 
the  right  upper  and  lower  extremities.  The  convulsions  recurred  at 
short  intervals,  and  atrophy  of  the  paralyzed  limbs,  with  contractions 
of  the  fingers,  hand,  and  forearm,  supervened.  She  learned  to  walk, 
however,  quite  well,  and  also  to  talk  without  any  very  notable  defects. 

Her  mind  was  Aveak,  and  she  Ws  extremely  silly  in  her  behavior;  she 
had  never  learned  to  read. 

Under  the  use  of  the  bromide  of  potassium  her  epileptic  paroxysms 
ceased,  but   the  contractions  and  atrophy  of   the   right   arm   resisted 


DIFFUSED   CEREBRAL   SCLEROSIS.  079 

treatment  by  galvanism  and  mechanical  appliances.  The  leg  acquired 
much  more  power  under  the  treatment  than  it  had  previously  possessed. 

Case  III. — W.  W.,  a  gentleman,  aged  forty-three,  came  to  me,  De- 
cember 11, 18G9,  to  be  treated  for  what  his  physician  and  friends  regarded 
as  softening  of  the  brain. 

About  six  months  previously  he  had  experienced,  on  awaking  in  the 
morning,  great  difficulty  in  extending  the  left  hand  and  fingers,  and 
through  the  whole  day  there  was  a  decided  tendency  manifested  for  the 
latter  to  close,  and  the  hand  to  be  flexed  upon  the  forearm;  and  this 
gradually,  day  after  day,  became  stronger,  till  at  last  neither  the  hand 
nor  fingers  could  be  extended. 

Then  the  corresponding  lower  extremity  became  involved  in  a  similar 
manner,  and,  about  a  month  after  noticing  the  first  symptom,  he  had 
an  epileptiform  convulsion,  and  this  was  repeated  twice  the  following 
day.  Since  then  the  fits  have  occurred  at  intervals  of  four  or  five  days. 
"With  the  contractions  in  the  limbs  of  the  left  side,  there  was  gradually- 
advancing  paresis  until,  when  he  came  under  my  observation,  both  arm 
and  leg  were  almost  completely  paralyzed.  Atrophy  of  both  extremi- 
ties was  present  to  an  extreme  degree,  and  sensibility  and  electro-mus- 
cular contractibility  were  almost  entirely  abolished. 

His  mind  was  also  notably  impaired.  He  laughed  immoderately  at 
every  question  I  put  to  him,  and  had  a  decided  expression  of  imbecility. 
His  speech  was  not  affected  to  any  remarkable  degree,  except  as  regarded 
extreme  slowness  of  utterance.  He  had,  previously  to  his  illness,  been 
a  ready  and  quick  speaker.  My  diagnosis  was  diffused  cerebral  sclero- 
sis, and  I  gave  an  unfavorable  prognosis.  The  treatment,  which  will  be 
considered  under  its  proper  head,  was,  however,  successful  to  a  very  con- 
siderable extent. 

It  will  be  seen,  from  the  foregoing  account  of  the  symptoms,  that 
diffused  cerebral  sclerosis  is  characterized  mainly  by  weakness  of  intel- 
lect, paralysis,  and  muscular  contractions. 

Causes. — The  predisposing  causes  of  the  affection  under  considera- 
tion are  not  thoroughly  understood.  The  disease  appears  to  be  much 
more  frequent  in  infancy,  although  it  lasts  to  the  period  of  old  age,  and 
sometimes  originates  at  an  advanced  time  of  life. 

The  exciting  causes  are  likewise  imperfectly  known.  Injuries  of  the 
skull  from  falls  or  blows,  and  hemorrhagic  cysts,  appear  to  have  some 
influence  in  originating  th  but  more  generally  it  is  developed, 

so  far  11  perceive,  spontaneously. 

Diagnosis. — The  diagnosis  of  diffused  cerebral  solerosis  must  always 
ore  or  less  uncertain,  for  the  reason  that  the  sympl  mel  with 

in  othi-r  very  different  affections.  In  children  a  similar  set  of  phenonv 
may  be  the  consequence  of  arrest  of  development  in  the  brain  with- 
out any  alteration  <>f  its  structure  recognizable  by  our  in  beer- 
n.     In  the  case  <>f  an  idiotic  child  affected  with  com  ulsions,  hemi- 


280  DISEASES   OF   TIIE   BRAIN. 

plegia,  and  muscular  contractions,  I  found,  on  post-mortem  examination, 
the  left  hemisphere  markedly  smaller  than  the  right,  but  I  could  detect 
no  change  of  any  part  of  its  structure. 

Symptoms  like  those  met  with  in  diffused  cerebral  sclerosis  mav  re- 
sult from  brain-tumors  of  various  kinds. 

In  adults  the  disease  is  readily  discriminated  from  cerebral  haemor- 
rhage and  embolism  by  the  gradual  character  of  its  advance,  and  by  the 
mental  symptoms  being  more  strongly  pronounced.  But  from  soften- 
ing the  diagnosis  cannot  always  be  made  out,  and  an  opinion  must  be 
formed  from  the  history  and  phenomena  in  each  individual  case. 

From  thrombosis  the  diagnosis  is  equally  difficult.  Perhaps  the  dis- 
tinction may  be  made  both  as  regards  softening  and  thrombosis  by  the 
facts  that,  though  contractions  are  met  with  in  both  these  diseases,  they 
are  not  such  invariable  accompaniments  as  they  are  in  diffused  cerebral 
sclerosis,  and  that  they  are  never,  as  occasionally  in  the  latter  affection, 
a  primary  symptom. 

Prognosis. — The  prospect  of  complete  recovery  is  very  gloomy,  and 
even  amelioration  has  hitherto  been  regarded  as  out  of  the  question.  I 
am  inclined,  however,  to  think,  as  the  result  of  my  own  experience,  that 
the  condition  of  patients,  apparently  suffering  from  the  affection  in 
question,  may  be  decidedly  improved  by  suitable  medical  treatment. 
I  have  several  times  succeeded  in  arresting  the  convulsions,  strength- 
ening the  mind,  increasing  the  strength  and  sensibility  of  the  paralyzed 
members,  and  relaxing  the  contractions.  My  success  has  been  much 
more  decided  in  cases  which  had  originated  late  in  life — probably,  for 
the  reason  mainly  that  the  disease  was  seen  earlier  in  its  course. 

Morbid  Anatomy. — This  division  of  the  subject  has  already  been  con- 
sidered incidentally,  to  some  extent,  in  the  remarks  made  under  the 
head  of  symptoms,  and  in  the  detail  of  cases  quoted. 

The  most  obvious  feature  detected  by  ordinary  observation  is  the 
increased  hardness  and  density  which  the  cerebral  tissue  has  acquired. 
This  generally  occupies  a  considerable  portion  of  one  lobe,  or  may  ex- 
tend through  the  whole  of  it,  or  may  even  affect  a  whole  hemisphere. 
It  is  not  distinctly  circumscribed,  but  diminishes  in  intensity  from  the 
centre  to  the  periphery,  and,  according  to  Pinel,  never  invades  the  gray 
substance. 

The  increased  density  is  attended  with  atrophy  when  the  disease 
affects  the  adult,  and  with  atrophy  and  arrest  of  development  when 
children  are  its  subjects. 

In  order  to  understand  the  essential  nature  of  the  morbid  process 
which  causes  the  brain  to  become  indurated,  a  few  words  in  regard  to 
cerebral  histology  are  necessary. 

Besides  the  nervous  tissue  of  the  brain,  there  is  another  anatomical 
element  present  which  fulfills  the  function  of  binding  the  cells  and  fibres 
together,  and  giving  the  whole  substance  its  normal  degree  of  consist- 


DIFFUSED   CEREBRAL   SCLEROSIS.  281 

ence.  According  to  Virchow,1  this,  although  analogous  to,  is  different 
in  some  respects  from  ordinary  connective  tissue.  He  gave  to  it  the 
name  of  neuroglia  or  nerve-cement. 

Diffused  cerebral  sclerosis  consists  in  the  hypertrophy  or  increased 
formation  of  this  tissue,  and  the  atrophy  or  disappearance  of  the  proper 
nervous  substance.  Atrophy  of  the  brain  may,  however,  be  due  to 
other  causes  than  sclerosis,  as  in  the  case  reported  with  great  minute- 
ness by  Schroeder  van  der  Kolk,2  and  several  of  those  cited  by  Lalle- 
mand,3  Turner,4  and  other  writers. 

Pathology. — The  symptoms  which  result  from  diffused  cerebral  scle- 
rosis are  those  which  we  might  expect  to  be  the  consequence  of  a  con- 
dition which  essentially  consists  of  a  disappearance  of  that  part  of  the 
brain-tissue  capable  of  producing  or  transmitting  nervous  force,  and  the 
substitution  of  another  histological  element  which  is  of  secondary  im- 
portance. They  all  indicate  deficient  cerebral  power.  It  is  with  the 
brain  as  with  a  muscle  undergoing  atrophy:  less  force  results  from  its 
action  in  correspondence  with  the  advance  of  the  process  by  which  the 
characteristic  anatomical  elements  disappear. 

Doubtless,  if  we  had  the  opportunity  of  more  thorough  study  of 
the  symptoms  of  diffused  cerebral  sclerosis,  and  comparing  them  with 
the  condition  of  the  brain  as  found  by  post-mortem  examination,  we 
should  find  that  they  varied  considerably  in  character,  according  to  the 
part  affected,  and  we  should  probably  have  reason  to  believe  that  the 
nerve-cells  which  had  disappeared — motor,  sensitive,  or  trophic — were 
in  exact  pathological  relation  with  the  symptoms  observed.  This  spe- 
cial point  has  been  well  studied  by  MM.  Duchenne  de  Boulogne  and 
Jouffroy,6  in  a  recent  paper,  devoted  to  a  somewhat  different  disease, 
and  to  which  I  have  recently  been  enabled  to  add  a  few  important 
data. 

Treatment. — This  division  of  the  subject  has  scarcely  received  any 
attention  from  authors.  My  experience,  however,  has  sufficed  to  con- 
vince me  that  we  can  occasionally  improve  the  condition  of  the  patient. 

If  there  arc  epileptic  convulsions,  they  may  be  prevented  by  the  ad- 
ministration of  the  bromide  of  potassium,  in  doses  of  at  least  twenty 
grains,  three  times  a  day,  to  an  adult.  Larger  doses  may  be  necessary. 
On  the  cessation  of  the  convulsions,  it  will  sometimes  be  found  that  the 
intelligence  at  once  begins  to  be  developed. 

The  paralysis  and  contractions  may  sometimes  be  lessened  by  the 

llular  Pathology,"  Chance's  translation,  London,  1860,  p,  277. 

*  "A  Case  of  Atrophy  of  .the  Left  Hemisphere  of  the  Brain,"  etc  New  Sydenham  So- 
olety  Translation,  London,  1861. 

*  Op.  ■■;/. 

4  "  De  I'atrophie  partielle  <>m  onilaterale  do  eerrelet,"  1 1 

'"  De  I'atrophie  algae*  el  ohronique  dea  oellnlea  Qerreuses  de  la  moelle  et  ilu  bulbe 
rachidien,"  etc.:  Archives  de  Phytiologie,  N<>.  l,  Jnillet  et  aout,  1870,  p.  199. 


282  DISEASES   OF  TIIE   BRAIN. 

persistent  use  of  both  the  induced  and  primary  galvanic  currents.  The 
first  named  will  often  in  the  beginning  fail  to  act  upon  the  muscles,  in 
which  case  the  latter  should  be  employed.  This  is  always  better  for 
the  contracted  muscles  than  the  induced  current.  For  the  relief  of 
the  paralysis  it  should  be  interrupted,  for  the  relaxation  of  contrac- 
tions it  should  be  constant. 

As  regards  the  central  lesion,  I  think  it  may  occasionally  be  reached, 
when  it  has  not  had  time  to  become  very  extensive  or  profound.  And 
the  best  and  really  only  means  I  know  of  are,  the  primary  galvanic 
current  passed  through  the  brain,  and  the  administration  of  the  iodide 
of  potassium,  which  unquestionably  has  the  power  of  preventing  the 
formation  of  new  connective  tissue. 

In  using  the  galvanic  current,  the  electrodes — wet  sponges — should 
be  applied  over  the  mastoid  processes,  and  kept  there  for  a  period  not 
exceeding  three  minutes.  From  three  to  eight  milliamperes,  according 
to  the  size  of  the  electrodes,  will  be  sufficient.  The  application  should 
be  made  about  every  alternate  day. 

I  am  unable  to  say  that  these  measures  have  actually  removed  the 
supposed  sclerosis  of  the  brain,  and  caused  the  reformation  of  the  atro- 
phied cells,  but  I  am  very  sure  that  symptoms  such  as  are  attendant 
upon  diffused  cerebral  sclerosis  have  several  times  been  measurably  dis- 
sipated by  its  influence.  Thus,  in  the  third  case  mentioned  as  occurring 
in  my  practice,  the  mind  improved,  the  epileptic  paroxysms  ceased,  the 
contractions  were  relaxed,  the  paralysis  lessened,  the  affected  limbs  in- 
creased in  size,  and  the  further  progress  of  the  disease  was  arrested. 
At  the  present  date  (December  30, 1870)  the  gentleman  is  able  to  take 
care  of  himself,  to  walk  tolerably  well,  and  to  use  the  formerly-para- 
lyzed arm  for  many  purposes.  In  three  other  cases  a  like  treatment 
has  been  productive  of  almost  as  marked  a  degree  of  benefit. 


CHAPTER  XIII. 

PARALYSIS    AG  I  TANS. 


It  is  only  of  late  years  that  the  affection  in  question  has  been  par- 
tially recognized  as  a  distinct  pathological  condition,  associated  with 
certain  symptoms.  These  symptoms  were  formerly,  and  still  are  to  a 
great  extent,  confounded  with  other  groups  similar  in  several  promi- 
nent features,  but  different  altogether  in  anatomical  relations,  normal 
and  abnormal. 

Thus,  under  the  designation  of  paralysis  agitans,  were  comprehended 
the  phenomena  due  to  multiple  cerebral  sclerosis,  multiple  cerebro- 
spinal sclerosis,  and  muscular  agitation,  general  or  local — the  result  of 


PARALYSIS   AGITAXS.  283 

very  dissimilar  lesions,  or  without  discoverable  morbid  changes  of  any 
kind — the  one  symptom  of  tremor  sufficing  to  bind  them  together. 
Even  by  late  writers  the  distinction  is  not  clearly  made  out. 

It  is,  in  the  present  state  of  our  knowledge,  impossible  to  say  in 
all  cases  what  part  of  the  intra-cranial  mass  is  affected.  Still,  we 
are  not  altogether  without  data  on  this  point,  and  an  attentive  con- 
sideration of  the  symptoms  will  often,  at  least,  enable  us  to  say  what 
ganglion  of  the  encephalon  is  the  main  seat  of  the  lesion.  But, 
mindful  of  the  fact  that  this  work  is  intended  to  be  practical,  I  shall 
not  venture  to  deal  with  pathological  refinements,  but  will  point  out, 
with  as  much  succinctness  as  possible,  one  form  of  the  morbid  process 
under  notice — a  form  which  I  think  I  am  enabled  to  describe,  from 
my  own  observations,  with  considerable  accuracy.  That  form  has 
been  designated — 

PARALYSIS    AGITAXS. 

Symptoms. — Among  the  first  symptoms  noticed  in  this  affection  is 
pain,  which  occurs  in  sharp  paroxysms  of  short  duration.  Sometimes 
the  sensation  is  as  instantaneous  as  an  electric  shock.  It  is  rarely  the 
case  that  there  is  any  extreme  constant  pain  experienced,  though  a 
feeling  of  fullness  or  constriction  is  occasionally  more  or  less  perma- 
nent. 

In  a  few  cases  the  first  observed  symptom  has  been  an  epileptic 
paroxysm. 

It  is  not  uncommon  to  meet  with  disorders  of  sensibility  in  other 
parts  of  the  body;  and  these  may  either  be  anaisthetie  or  I  actio 

in  character.  Probably  the  most  common  is  a  numbness  of  the  ends 
of  the  fingers  or  toes,  which  gives  the  sensation  of  cushions  when  ob- 
jects are  touched,  and  which  is  generally  confined  at  first  to  a  single 
upper  or  lower  extremity.  Shooting  pains,  something  like  electric 
shocks,  are  also  sometimes  experienced.  The  progress  of  the  disease  is 
almost  invariably  slow,  and  hence  several  months  may  elapse  before  any 
disorders  of  motility  are  experienced.  These,  however,  are  the  next 
symptoms  to  make  their  appearance,  and  are  generally  first  manifested 
by  the  occurrence  of  tremor  or  trembling. 

Tremor  usually,  but  not  always,  is  gradual  in  its  development,  and 
may  bo  restricted  to  narrow  limits.  It  may  at  first  only  be  felt  when 
the  patient  is  unusually  quiet,  and  has  not  his  attention  engaged.  Thus 
a  gentleman  told  me  he  had,  for  Beveral  months,  only  been  sensibl 
a.  vibration  in  his  arm  when  he  lay  down  al  night  It  was  then— from 
the  description  he  gave  me  -  limited  entirely  to  the  extensor  indi<  • 
the  left  hand,  and  was,  in  the  beginning,  not  stn.ng  enough  to  move 
the  finger.  When  I  firsl  saw  him,  several  years  afterward,  both  arms 
and  one  leg  were  Btrongly  agitated. 

In  another  case,  which  1  saw  almost  from  the  very  beginning,  the 


284  DISEASES   OF  TIIE   BRAIN. 

tremor  was  restricted  to  the  same  muscle  for  several  months,  and  then 
gradually  involved  the  extensors  and  flexors  of  the  hand.  And  in  sev- 
eral other  instances  which  have  come  under  my  notice,  the  onset  was 
equally  gentle.  But,  as  I  have  said,  this  is  not  always  the  case.  A  gen- 
tleman consulted  me  in  the  summer  of  1870,  who,  after  having  ex- 
perienced severe  darting  pains  in  the  head  and  through  the  limbs  on  the 
right  side,  was  suddenly,  while  in  his  field  overlooking  some  work,  seized 
with  a  violent  trembling  of  the  right  hand,  which  continued  for  several 
minutes,  notwithstanding  his  efforts  to  prevent  it.  A  few  days  subse- 
quently, he  had  another  accession  of  a  similar  kind  in  the  same  limb, 
and  by  degrees  the  intervals  became  shorter,  until,  in  the  space  of  a 
month,  the  tremor  was  constantly  present  except  when  he  slept,  and, 
when  I  saw  him,  had  extended  to  the  whole  arm,  and  to  the  lower  ex- 
tremity of  the  same  side. 

In  another  case,  a  gentleman,  much  addicted  to  excessive  mental 
exertion,  was  awakened  one  morning  by  a  violent  agitation  in  his  right 
foot.  He  had  been  under  my  care  several  months  previously  for  severe 
headache  and  inability  to  sleep,  for  which,  believing  them  to  result  from 
inordinate  intellectual  labor,  I  had  recommended  mental  rest  and  horse- 
back exercise.  Under  the  use  of  these  measures  he  had  apparently  quite 
recovered,  but  against  my  advice  had  resumed  his  literary  labors. 

He  was  not  very  confident  how  long  the  shaking  of  the  foot  had 
lasted,  but  thought  it  was  not  more  than  a  few  seconds. 

Several  days  afterward,  while  writing,  his  right  hand  began  to  trem- 
ble slightly.  He  ceased  his  occupation,  and  rubbed  his  hand  with  the 
other.  The  tremor  stopped  for  a  moment  only,  again  began,  and  has 
scarcely  ever  since  been  absent.  The  whole  side  eventually  became 
involved. 

The  tendency  of  the  tremor  is  alwaj'S  to  extend.  Beginning  in  an 
extremity  or  a  group  of  muscles,  or  only  in  a  single  muscle,  it  goes  on 
attacking  others,  until  at  last  all  the  limbs  and  even  the  head  may  be- 
come affected.  By  preference,  the  advance  of  the  tremor  is  lateral, 
that  is,  if  an  arm  be  first  invaded,  the  leg  of  the  same  side  next  suffers, 
then  the  other  arm,  and  then  the  corresponding  leg.  Usually  the  head 
is  the  last  part  attacked;  but  this  is  not  always  so,  as  I  have  seen  sev- 
eral cases  in  which  the  trembling  began  in  it. 

For  a  long  time  the  tremor  is  to  some  extent  under  volitional  con- 
trol. A  patient,  for  instance,  will  slap  his  tremulous  hand  on  his  knee 
and  for  a  few  seconds  can  manage  to  keep  it  quiet,  but  it  soon  begins 
to  shake  again,  and,  though  perhaps  a  second  time  he  may  arrest  its 
movements  by  a  like  process,  the  period  of  rest  is  shorter.  Any  change 
of  position  is  calculated  to  quiet  the  tremor  for  a  time,  and  thus  the 
patient  is  every  few  minutes  moving  his  arms  or  legs  in  the  attempt  to 
get  a  little  respite. 

It  is  always  increased  by  emotional  disturbance  of  any  kind.     A 


PARALYSIS  AGITANS.  285 

limb  which  may  ordinarily  be  but  slightly  tremulous,  will  shake  vio- 
lently from  the  excitement  or  anxiety  produced  by  making  a  visit  to  a 
physician.    The  effort  to  keep  it  quiet  will  also  often  increase  the  tremor. 

For  a  very  considerable  period  after  the  beginning  of  the  disease,  the 
shaking  ceases  during  sleep,  but  eventually  this  state  affords  no  respite, 
and  the  patient  is  thus  deprived  still  further  of  his  physical  strength. 

It  is  not  often  the  case  that  the  muscles  of  the  face  are  affected  very 
earlv  in  the  disease,  but  they  frequently  become  involved  at  a  later 
period.  In  several  cases  I  have  seen  a  constant  tremor  in  the  upper 
eyelid  of  one  or  both  sides,  and  in  one  instance  this  was  the  first  mani- 
festation of  the  disease. 

In  another  very  remarkable  case  the  first  indication  of  tremor  was 
perceived  in  the  left  eyeball,  which  was,  by  clonic  spasms  of  the  inter- 
nal rectus  muscle,  kept  in  a  state  of  motion  producing  a  kind  of  nys- 
tagmus. The  upper  lid  of  the  same  eye  next  became  affected,  and  then 
the  tremor  appeared  in  the  corresponding  arm.  The  upper  lip  I  have 
several  times  seen  tremulous,  causing  thereby  an  indistinctness  in  the 
articulation. 

I  have  never  observed  other  muscles  supplied  by  the  facial,  or  tliird 
nerve,  to  be  involved  in  the  tremor. 

Occasionally  the  lower  jaw  is  rendered  tremulous  from  the  seat  of 
the  disease  being  at  the  origin  or  in  the  course  of  the  fifth  nerve. 

The  tongue  is  sometimes  affected  with  tremor,  generally  at  first  on 
only  one  side,  and  I  am  inclined  to  think  that  the  muscles  of  the  phar- 
ynx and  larynx  do  not  invariably  escape. 

The  tremor  is  not,  as  some  authors  have  asserted,  only  manifested 
when  voluntary  movements  are  performed.  This  is  probably  the  case 
at  least  in  the  first  instance  with  multiple  cerebro-spinal  sclerosis,  but 
it  certainly  is  not  in  the  disease  now  under  consideration.  Jaccoud  * 
calls  attention  to  the  error  which  has  been  committed  relative  to  this 
point,  and  my  own  experience  is  uniformly  in  support  of  the  opinion 
he  expresses. 

The  next  symptom  of  importance  to  make  its  appearance  is  paraly- 
sis; and,  as  the  lesion  is  limited  to  the  hemispheres  or  begins  in  them, 
it  always  follows  the  tremor.  On  this  point  1  have  insisted  in  my 
lectures  to  the  class  of  the  Bellevue  Hospital  Medical  College,  as  an 
important  indication  of  the  Tact  that  paralysis  agitans  is  always  a  cere- 
bral disease,  and  I  am  glad  to  find  so  exact  an  observer  as  Jaccoud1 
asserting  that  the  paralysis  is  often  preceded  by  muscular  agitation  or 
trembling. 

At  first  the  loss  of  power  is  slight,  and,  like  the  trembling,  is  limited 

to  a  single  muscle  or  group  of  muscles,  but  it  gradually  extends  until 

it  involves  the  limlis  of  one  Bide,  or  even  of  both  Bides.     According  to 

my  observations,  it  follows  the  course  of  the  trembling,  no  limb  being 

. '  "Traito  dc  pathologle  Interne,"  p.  191.  *  Op.  d  loc.  ciu 


286  DISEASES   OF   THE   BRAIN. 

ever  paralyzed  till  it  has  for  some  time  been  affected  with  tremor. 
In  the  face,  however,  the  paralysis  appears  to  be  independent  of  the 
tremor. 

The  period  which  elapses  between  the  appearance  of  the  tremor  and 
the  accession  of  the  paralysis  varies  in  different  patients,  and  even 
greatly  in  the  same  patient.  Thus  some  muscles  may  exhibit  notable 
loss  of  power  in  a  few  weeks  after  they  have  begun  to  be  agitated,  while 
others  remain  free  from  paresis  for  many  months. 

When  the  loss  of  power  affects  the  extensors  or  flexors — especially 
in  the  former  event — contractions  may  take  place,  as  in  diffused  cere- 
bral sclerosis,  and  the  limbs  are  thus  more  or  less  distorted.  The  most 
common  seat  of  this  phenomenon  is  in  the  upper  extremity,  and  it  gen- 
erally begins  in  the  fingers,  extending  gradually  to  the  wrist  and  elbow. 
But  in  some  cases,  even  though  the  antagonism  between  certain  groups 
of  muscles  be  destroyed,  there  are  no  contractions.  The  muscles  of  the 
head,  face,  and  trunk,  do  not  escape.  Strabismus,  ptosis,  and  facial 
paralysis,  are  thus  produced,  and  the  muscles  concerned  in  speech,  in 
deglutition,  and  in  respiration,  likewise  become  involved.  The  sphinc- 
ters, according  to  my  experience,  are  rarely  paralyzed  in  the  early  stages 
of  the  disease,  but  I  have  several  times  witnessed  paresis  of  the  bladder 
among  the  primary  symptoms. 

A  marked  symptom  which  I  have  observed,  and  which  can  only  be 
distinctly  shown  by  means  of  the  dynamograph,  is  the  inability  of  the 
patient  to  maintain  a  continuous  muscular  contraction,  for  even  a  short 
period.  I  have  noticed  this  as  among  the  very  first  indications  of 
paresis,  and  I  am  disposed  to  think  it  exists  even  before  the  tremor 
is  noticed.     Thus,  a  gentleman  occupying  a  prominent  public  posi- 

Fig.  18. 


tion,  and  in  whom  I  had  diagnosticated  paralysis  agitans,  instead  of 
making  a  straight  line  with  the  pencil  of  the  instrument,  traced  one 
of  which  Fig.  18  is  a  facsimile.  Repeated  efforts  only  gave  worse 
results. 

In  another  case,  that  of  a  gentleman  referred  to  me  by  my  friend 
Dr.  Van  Buret),  the  line  made  was  as  shown  in  Fig.  19.  Here  the 
patient  was  able  to  maintain  the  contraction  at  its  original  force  for 
only  about  the  sixth  of  a  minute — the  time  required  for  the  paper  to 
traverse  the  pencil  being  exactly  half  a  minute,  and  a  third  part  of  the 
line  bciner  horizontal. 


PARALYSIS   AGITANS.  287 

The  ability  to  coordinate  the  affected  muscles  is  always  impaired, 
and  thus  in  voluntary  movements  there  is  agitation  independently  of 


Fig. 


the  esoteric  tremor.  This  is  seen  not  only  in  active  movements,  hut  in 
passive  muscular  contractions,  such  as  those  by  which  an  article  is  held 
in  the  hand.  In  such  a  case  the  fingers  cannot  be  kept  in  apposition 
with  the  object,  but  are  moved  about  in  a  disorderly  manner.  The 
incoordination  is  manifestly  connected  with  the  inability  to  maintain  a 
lengthened  muscular  contraction  to  which  reference  has  just  been  made. 

Sometimes,  by  the  strong  effort  of  the  will,  assisted  by  the  sense  of 
sight,  these  last  two  difficulties  may  for  a  little  while  be  overcome.  A 
gentleman  now  under  my  charge,  suffering  from  the  affection  in  ques- 
tion, cannot,  for  instance,  carry  a  glass  of  water  to  his  lips  except  by 
looking  at  it  fixedly,  and  concentrating  all  his  volitional  power  upon 
the  act.  His  lower  limbs  are  not  yet  affected,  and  he  consequently 
can  coordinate  them,  in  walking  and  other  movements,  perfectly  well. 

In  another  case,  a  lady,  affected  with  paralysis  agitans,  undertook 
to  help  her  invalid  husband  to  rise  from  his  chair ;  a  band  of  music 
happening  to  pass  the  window,  she  turned  to  look  at  it,  and,  at  once 
relaxing  her  hold,  let  him  fall  to  the  floor  and  injured  him  severely. 

Zenker'  reports  a  case  in  which  there  was  a  similar  loss  of  the  ap- 
preciation of  the  state  of  the  muscle  ;  and  another  is  mentioned  by 
Reynolds,2  under  the  head  of  "muscular  anaesthesia."  I  am  very  sure 
that  many  cases  of  this  last-named  affection  are  instances  of  paralysis 
agitans,  and  I  shall  presently  more  specifically  refer,  under  a  differ- 
ent head,  to  two  remarkable  cases  which  have  occurred  in  my  own 
experience. 

Another  phenomenon  closely  related  with  this  incoordination  is  gen- 
erally present  in  paralysis  agitans,  and  that  is,  that  the  p.-'.ticnt  loses 
that  innate  or  early-acquired  knowledge  of  the  exact  situation  of  the 
several  parts  of  his  body.  We  can  all  of  us,  not  thus  affected,  close 
our  eyes,  and  touch,  with  the  end  of  the  finger,  any  particular  point  on 
the  face  or  rest  of  the  hotly,  with  the  utmost  exactness.  Bat  a  person 
with  paralysis  agitans  cannot  do  this.  Thus,  in  attempting,  with  the 
eyes  shut,  to  place  the  end  of  the  index-finger  on  the  middle  of  the 
eyebrow,  ho  misses  that  point,  sometimes  by  as  much  as  two  inches; 
and  no  matter  how  frequently  ho  tries,  he  succeeds  no  better.  It 
would  appear  that,  in  such  cases,  the  normal  instinct  of  topographical 

1  "  Kin   Beitrag  zur  Sklerose  dea  Minis  und  Ruckenmarka,"   Henle  und  Pfeu/er'a 

Zcitschrift  fur  rationelU  Medvein,  Bd.  \\i\\,  1865. 
8  "  System  of  Medicine,"  vol.  ii.,  p.  330. 


288  DISEASES   OF   THE   BRAIX. 

relation  between  the  fingers  and  the  cutaneous  surface  generally,  which 
all  persons  and  many  animals  seem  to  possess,  is  impaired.  This  is 
termed  the  "  muscular  sense." 

The  electro-muscular  contractility  is  never,  according  to  my  ex- 
perience, diminished  in  paralysis  agitans,  uncomplicated  with  similar 
lesions  in  the  spinal  cord. 

The  attitude  and  gait  of  a  person  affected  with  paralysis  agitans 
are  peculiar.  In  standing,  the  body  is  generally  inclined  forward,  the 
head  falling  toward  the  chest,  the  trunk  flexed  at  the  pelvis,  and  the 
knees  slightly  bent.  In  walking,  the  action  is  similar  to  a  jog-trot,  the 
body  being  still  inclined  forward,  and  the  patient  often  moving  with 
considerable  rapidity.  I  have  had  several  persons  with  the  disease 
under  my  charge  who  could  not  walk  at  all,  but  who  could  run  with 
surprising  agility.  One  of  these,  a  gentleman  advanced  in  life,  sent  to 
me  by  my  friend  Prof.  Sayre,  was  unable  to  take  a  step  in  my  consult- 
ing-room. He  was  carried  down-stairs  by  his  attendants  with  some 
difficulty,  and  when  he  reached  the  front-door  he  was  put  on  his  feet. 
He  then  told  his  servant  to  give  him  a  push,  which  the  man  did  with 
all  his  might,  and  the  old  gentleman,  being  started,  went  at  a  full  run 
and  jumped  into  his  carriage  without  the  least  difficulty.  This  con- 
dition is  known  as  "festination." 

There  is  often  a  strong  tendency  to  plunge  forward,  and  at  times 
there  is  an  impossibility  of  controlling  it  except  by  catching  hold  of 
some  fixed  object.  Not  long  since  I  was  walking  down  Broadway, 
when  I  saw  in  front  of  me  a  gentleman  who  was  then  under  my  charge, 
and  in  whom  I  had  diagnosticated  paralysis  agitans.  Although  awTare 
of  his  peculiar  impulsive  gait,  I  had  never  seen  it  so  strikingly  mani- 
fested as  it  was  then.  He  went  at  a  full  trot,  threading  his  way  among 
the  numerous  people  in  the  street,  until,  apparently  exhausted,  he 
would  lay  hold  of  a  lamp-post  or  awning-post  and  cling  to  it  till  he 
had  recovered  his  breath,  to  start  off  again  in  a  similar  manner. 

This  impulsion  of  the  body  forward  makes  it  easy  for  the  patient  to 
ascend  a  staircase,  but,  on  the  contrary,  very  difficult  to  go  down  one. 

The  first  case  of  the  disease  in  question  which  I  saw  in  this  city, 
over  six  years  ago,  was  characterized  by  an  extreme  degree  of  festina- 
tion. It  was  that  of  a  maiden  lady,  over  fifty  years  of  age,  who  had 
been  affected  fur  several  years.  "When  she  was  going  up-stairs  no  one 
could  perceive  the  least  irregularity  in  her  gait,  but  to  go  down  was 
impossible. 

Sometimes,  however,  the  tendency  is  to  go  backward.  This  was 
the  case,  to  a  remarkable  extent,  in  a  gentleman,  a  resident  of  this 
city,  who  was  sent  to  me  by  Prof.  Van  Buren.  Every  time  he  rose 
from  his  chair  he  was  forced  to  take  several  steps  backward,  and  it  was 
only  by  constant  mental  effort  that  he  was  able  to  go  forward  at  all. 

The  tactile  sensibility  is  generally  impaired  from  a  very  early 


PARALYSIS   AGITAXS.  289 

period  in  the  course  of  the  affection,  and  thus  the  two  points  of  the 
aesthesiometer  must  be  more  widely  separated  than  in  the  normal  con- 
dition of  the  system,  in  order  to  get  two  separate  impressions.  This 
anaesthesia  bears  no  necessary  relation  to  the  region  of  skin  covering 
the  affected  muscles.  According  to  my  experience,  it  is  most  marked 
at  the  terminal  extremities  of  nerves. 

Numbness  of  different  degrees,  pains  of  various  kinds,  increased 
or  diminished  temperature,  and  excessive  hyperesthesia  of  the  skin, 
may  also  exist. 

As  paralysis  agitans  is  purely  a  cerebral  affection,  the  "knee-jerk" 
will  be  found  to  be  normal,  and  the  ankle-clonus  cannot  be  obtained. 
In  cases  where  the  knee-jerk  is  increased  and  the  ankle-clonus  is  pres- 
ent there  is  reason  to  believe  that  the  antero-lateral  columns  of  the 
cord  have  become  affected  either  secondarily  or  independently. 

The  special  senses  may  be  affected  to  a  variable  extent.  Thus 
there  may  be  amblyopia,  or  even  complete  blindness  ;  the  taste  is  very 
often  impaired  or  abolished,  and  the  hearing  rendered  less  acute. 

The  ophthalmoscope  should  always  be  employed  to  examine  the 
fundus  of  the  eye.  The  condition  generally  found  to  exist  is  white 
atrophy  of  the  optic  disk,  which  is  identical  in  general  features  with 
sclerosis.  The  vessels  of  the  retina  will  usually  be  found  small,  the 
branches  of  the  veins  few  in  number,  and  the  choroid  of  a  paler  hue 
than  is  natural. 

The  course  of  paralyis  agitans  is  progressive. 

The  patient  is  finally  unable  to  walk,  the  friction  of  his  shaking 
body  against  the  bed  abrades  the  skin,  the  dejections  are  passed  in- 
voluntarily, and  he  dies  either  in  coma,  in  convulsions,  or  by  a  gradual 
process  of  asthenia,  his  mind  participating  in  the  general  decay.  The 
duration  of  the  disease  varies  from  a  few  months  to  eight  or  ten  years. 
Generally  it  runs  its  course  in  about  five  years. 

Causes. — Age  is  certainly  one  of  the  most  powerful  predisposing 
causes  of  paralysis  agitans.  Thus,  of  thirteen  cases  in  which  I  diag- 
nosticated the  disease  in  question,  all  were  over  fifty  years  of  age,  and 
six  were  over  sixty.  I  have  seen  numerous  cases  of  paralytic  tremor 
in  younger  persons,  but  the  morbid  condition  had  scarcely  any  points 
in  common  with  that  now  under  notice.  Cases,  however,  are  on  record 
in  which  young  persons  were  the  subjects.  There  is  some  evidence  to 
support  the  theory  that  it  is  sometimes  hereditary,  but  the  whole  sub- 
ject is  so  confused  in  the  minds  of  most  authors  that  it  is  difficult  to 
make  out  clearly  what  they  refer  to  under  the  designation  of  paralysis 
agitans.  Of  the  thirteen  cases  occurring  in  my  own  practice,  private 
and  hospital,  live  bad  immediate  ancestors  who  had  suffered  from 
some  form  of  tremor  and  paralysis.  Whether  the  lesion  was  purely 
cerebral,  cerebro-spinal,  or  whether  the  disease  was  entirely  functional, 
T  was  not  able  to  decide  from  the  information  given. 
20 


290  DISEASES   OF   THE   BRAIN. 

The  influence  of  sex  is  more  readily  ascertained  and  is  very  evi- 
dent.    Eleven  of  my  cases  were  males  and  only  two  females. 

Of  exciting  causes  there  are  many.  In  two  of  my  cases  it  followed 
immediately  on  attacks  of  scarlet  fever,  in  two  it  was  a  sequence  of 
typhoid  fever,  in  two  it  ensued  after  rheumatism,  in  two  it  was  prob- 
ably syphilitic,  in  two  it  was  apparently  excited  by  great  emotional 
disturbance,  in  one  by  inordinate  muscular  exertion,  and  in  three  no 
cause  could  be  assigned,  or  at  least  there  was  not,  in  my  opinion,  any 
sufficient  exciting  cause  to  be  discovered. 

Diagnosis. — Paralysis  agitans  has  heretofore  been  confounded  with 
other  diseases,  and  its  very  existence  as  an  independent  affection  is 
very  illogically  questioned  by  some  writers. 

The  occurrence  of  "head-symptoms"  is  sufficient  to  diagnosticate 
paralysis  agitans  from  functional  tremor,  which  is  never  a  very  serious 
affection,  and  the  seat  of  which  is  not  always  centric.  Besides,  in  the 
latter  there  are  no  festination,  alterations  of  sensibility,  incoordina- 
tion, muscular  anaesthesia,  or  inability  to  maintain  a  continuous  muscu- 
lar contraction,  while  the  paper  of  the  dynamograph  traverses  the 
pencil  of  the  instrument.  The  functional  disorder  is  more  liable  to 
occur  in  persons  under  fifty  than  in  those  over  that  age.  From  the 
cerebro-spinal  form  of  multiple  sclerosis,  which  will  be  fully  consid- 
ered in  another  section  of  this  work,  it  is  distinguished  mainly  by  the 
facts  that  the  tremor  makes  its  appearance  before  the  paralysis,  and 
that  the  agitation  is  present  whether  voluntary  movements  are  being 
made  or  not. 

With  the  purely  spinal  form  it  is  not  likely  to  be  confounded  by 
any  one  paying  the  slightest  attention  to  the  phenomena  of  the  two 
diseases. 

From  chorea  it  might  in  some  cases  not  be  readily  discriminated 
without  a  thorough  study  of  the  clinical  history  and  existing  symp- 
toms. But,  though  chorea  sometimes  occurs  in  adults,  and  is  gener- 
ally accompanied  by  "head-symptoms,"  the  two  affections  possess  few 
other  phenomena  in  common. 

In  the  first  place,  the  mental  symptoms  in  chorea  are  indicative  of 
feebleness  from  the  very  first,  while  in  paralysis  agitans  imbecility 
supervenes  late  in  the  course  of  the  disorder.  In  chorea  there  are  no 
vertigo,  pain  in  the  head,  or  other  evidences  of  congestion,  while  in 
the  disease  under  notice  these  are  among  the  very  earliest  symptoms. 
In  chorea  there  is  no  actual  tremor,  but  the  disorderly  movements  are 
more  extensive  and  irregular  than  in  multiple  cerebral  sclerosis  ;  nei- 
ther is  there  festination  or  bending  of  the  body  forward. 

Tremor  is  sometimes  met  with  after  cerebral  hemorrhage  or  other 
cause  producing  hemiplegia,  but  in  such  cases  the  clinical  history,  and 
the  fact  that  the  trembling  comes  on  after  the  paralysis,  will  suffice  to 
render  the  diagnosis  sure. 


PARALYSIS   AGITAXS.  291 

Prognosis. — The  prospect  of  recovery  is  always  unfavorable,  but 
not,  I  am  induced  to  think,  absolutely  hopeless  if  the  patient  be  seen 
sufficiently  early  in  the  course  of  the  disease  and  submitted  to  proper 
medical  treatment.  The  probability  of  an  arrest  of  the  onward  ten- 
dency is  by  no  means  small  under  like  circumstances.  Still,  in  the 
great  majority  of  cases,  all  means  fail,  and  the  affection  gradually  and 
persistently  goes  on  to  its  termination — death. 

Morbid  Anatomy. — So  many  and  widely  different  lesions  have  been 
discovered  by  competent  observers,  both  in  the  brain  and  in  the 
spinal  cord,  in  cases  of  paralysis  agitans,  that  we  are  forced  to  admit 
that  the  precise  seat  of  the  leision  is  as  yet  unknown.  In  a  number 
of  instances  no  lesion  has  been  discovered  at  all.  In  a  case  of  my 
own,  a  man  who  had  been  under  my  observation  for  eight  years,  and 
who  was  a  typical  example  of  the  disease,  not  the  slightest  lesion 
could  be  discovered  in  the  brain  or  cord,  although  careful  gross  and 
microscopical  examinations  were  made.  Death  followed  soon  after 
the  appearance  of  bulbar  symptoms.  There  were  difficulty  in  swal- 
lowing, feeble  respiration,  and  irregular  and  weak  heart,  and  finally 
death  ensued,  evidently  from  paralysis  of  the  pneumogastric,  and  yet 
no  lesion  could  be  discovered  either  in  the  medulla,  basal  ganglia,  or 
cortex.  Unquestionably  there  was  a  lesion,  but  the  methods  of  ex- 
amination such  as  we  possess  at  the  present  day  were  inadequate  to 
discover  it.  Similar  cases  are  reported  by  Charcot,  Berger,  Westphal, 
Ordenstein,  Ileimann,  and  others.  In  the  majority  of  instances  lesions 
have  been  discovered,  but  they  were  not,  by  any  means,  limited  to 
one  region  of  the  brain.  Thus,  such  lesions  as  softening,  sclerosis,  and 
tumors  involving  the  cortex,  the  thalami  and  striati,  the  pons,  the  me- 
dulla, and  the  internal  capsule,  have  been  observed  at  various  times. 
At  heromatous  degenerations  of  the  blood-vessels  is  not  uncommon, 
and  in  many  cases  spinal  lesions — such  as  lateral  sclerosis,  degenera- 
tion of  Clark's  columns,  and  meningitis — constitute  the  only  apparent 
morbid  changes. 

Strum  pel  and  Gauthier  both  advance  the  theory  that  paralysis  av- 
ians is  primarily  a  muscular  affection,  without,  however,  in  my  opin- 
ion, having  any  good  reason  for  so  doing. 

Pathology. — From  the  fact  that  the  lesions  resulting  in  paralysis 
agitans,  when  they  an-  discovered  at  all,  are  so  inconstant  and  diverse, 
it  naturally  follows  that  the  pathology  must  he  mainly  speculative. 

Now,  in  m\  (.pinion,  Parkinson1  has  described  two  very  distinct 

affections  under  the   name  of  paralysis  agitans.      One  of  these    18    eer- 

1  "Essay  on  the  Shaking-Palsy,"  London,  lsi7.  in  the  previous  editions  of  this 
work  I  have  referred  t<>  mj  inability  to  obtain  a  copy  "f  Parkinson's  work,  and  thai  my 
citations  from  it  were  therefore  necessarily  second-hand.  Observing  this  statement,  Dr. 
T.  Wind  or,  of  Manchester,  England,  was  kind  enough  i"  present  me  n  iili  a  copj .  so  thai 
1  am  able  in  the  present  edition  to  refer  to  Parkinson  directly. 


292  DISEASES  OF   THE   BRAIN. 

tainly  functional  so  far  as  this  :  that  the  tremor  shows  no  disposition 
to  extend  to  distant  parts  of  the  body,  that  it  is  the  only  symptom 
present,  that  no  lesion  has  been  discovered,  and  that  it  is  readily  cured. 
The  cases  described  by  him,  on  pages  48  and  50  of  his  "  Essay,"  were 
of  this  form,  and  Case  IV.  was  probably  of  like  character.  The 
other  is  characterized  by  the  phenomena  which  I  have  detailed  in  this 
chapter,  and  which,  though  imperfectly  described  by  other  authors, 
have  either  been  confounded  with  multiple  cerebrospinal  sclerosis,  or 
regarded  as  constituting  an  aggravated  form  of  the  functional  dis- 
order. 

Parkinson  defines  it  as  "  involuntary  tremulous  motion,  with 
lessened  muscular  power,  in  parts  not  in  action  and  even  when  sup- 
ported ;  with  a  propensity  to  bend  the  trunk  forward,  and  to  pass 
from  a  walking  to  a  running  pace,  the  senses  and  intellect  being  unin- 
jured." 

Ordenstein *  is  of  the  opinion  that  the  true  anatomical  lesion  of 
non-spinal  tremor  is  yet  to  be  found,  although  he  refers  to  several 
cases  in  which  there  were  organic  changes  in  the  pons  Varolii,  me- 
dulla oblongata,  and  crura  cerebri.  These  he  regards  as  accidental, 
and  therefore  as  not  being  essential  features  of  the  disease.  It  is 
scarcely  necessary  to  say  that  he  does  not  make  the  distinction  be- 
tween multiple  cerebral  sclerosis  and  the  form  of  tremor  to  which  I 
restrict  the  name  of  paralysis  agitans,  and  the  morbid  anatomy  of 
which  is  still  undetermined. 

The  only  two  theories  in  regard  to  the  pathology  of  this  disease 
which  are  entitled  to  serious  consideration  are,  on  the  one  hand,  that 
it  is  of  cerebral  origin  ;  on  the  other  hand,  that  the  morbid  changes  are 
to  be  looked  for  in  the  spinal  cord.  In  regard  to  the  latter  theory, 
although  paresis,  rigidity,  and  various  sensory  anomalies  frequently 
accompany  spinal  lesions,  tremor  does  not ;  nor  are  festination,  scan- 
ning speech,  and  the  emotionless  expression  of  the  face,  symptoms 
which  can  be  attributed  to  morbid  conditions  of  the  spinal  cord. 

The  "  spinal  theory  "  has  again  been  quite  recently  advocated  by 
Teissier,"  who  reports  three  autopsies  where  the  only  morbid  condition 
observed  was  slight  diffused  sclerosis  of  the  lateral  columns,  yet  it 
seems  to  me  that  the  entire  train  of  symptoms  point  to  a  cerebral 
lesion  affecting  the  motor  tract,  and  that  where  the  spinal  cord  is  im- 
plicated it  is  either  from  an  extension  of  the  primary  morbid  process, 
or  else  is  an  independent  disease. 

I  have  long  been  of  the  opinion  that  mobile  spasm  in  any  form  is 
the  result  of  irritation  of  cerebral  motor  nerve  cells,  but  not  of  cerebral 
motor  conducting  fibres.  Irritation  of  the  latter  is  invariably  followed 
by  spastic  spasm.     The  regions  of  the  brain  in  which  motor  nerve 

1  "Sur  la  paralysie  a^itante,"  etc.,  Paris,  1868,  p.  20  el  seq. 

2  "  Lyon  med.,"  1888,  lviii. 


PARALYSIS   AGITANS.  293 

cells  are  known  to  exist  are  the  cortex,  the  striata,  the  medulla,  and  the 
pons,  and  irritative  lesions  in  these  regions  is  frequently  followed  by- 
some  form  of  mobile  spasm.  Hence  it  follows  that  the  different 
varieties  of  mobile  spasms,  as  exemplified  in  the  movements  of  chorea, 
athetosis  and  convulsions,  and  in  the  different  forms  of  tremor,  are 
very  closely  allied  one  with  the  other  as  far  as  their  pathological 
origin  is  concerned.  The  difference  in  the  external  manifestations  of 
the  muscular  movements  indicates  a  difference  in  the  degree  or  in 
the  form  of  the  central  irritation.  If  this  view  is  correct,  the  wide 
diversity  of  the  cerebral  lesions  discovered  in  paralysis  agitans  can,  in 
a  great  measure,  be  accounted  for.  In  the  majority  of  cases  of  paraly- 
sis agitans  there  are  both  tremor  and  rigidity.  Therefore  we  would 
expect  to  find  both  motor  nerve  cells  and  conducting  fibres  implicated 
in  the  morbid  process.  Hughlings  Jackson  advances  the  theory  that 
in  paralysis  agitans  there  is  wasting  of  the  motor  nerve  cells  in  the 
cortex  in  order  from  the  smallest  to  the  largest  cells.  This  hypothe- 
sis, if  it  is  made  to  include  the  cells  of  the  corpus  striatum  and  the 
pons,  coincides  accurately  with  my  own  views.  The  motor  conduct- 
ing fibres  must  also  be  involved,  to  account  for  the  spastic  muscular 
condition.  This  would  explain  satisfactorily  the  slight  diffused  scle- 
rosis of  the  lateral  columns  observed  by  Teissier  and  others,  for  it  is 
well  known  that  degeneration  beginning  in  the  cerebral  motor  tract 
generally  finds  its  way  to  the  motor  conducting  path  in  the  cord. 

The  most  probable  theory,  therefore,  which  would  account  satis- 
factorily, at  least  to  ray  mind,  for  the  symptoms  of  paralysis  agitans 
is  that  of  an  irritative  lesion  affecting  the  motor  nerve  cells  of  either 
the  cortex,  the  striata,  or  the  pons,  together  with  a  greater  or  less  de- 
generation of  the  motor  conducting  tract. 

Treatment. — To  detail  all  the  various  methods  which  have  been 
employed  in  the  treatment  of  the  group  of  symptons  which  I  have 
classed  together  as  paralysis  agitans  would  be  a  fruitless  piece  of 
labor.  Many  of  the  cases  of  cure  which  have  been  reported  were  not 
instances  of  the  disease  now  under  notice,  but  of  the  milder  and,  so 
far  as  we  know,  functional  disorder;  and  therefore  it  would  be  use- 
l'  ss  to  adduce  them  as  guides  in  the  present  connection.  I  shall 
therefore  confine  my  remarks  to  the  results  of  my  own  experience.  I 
am  very  sure  that  the  condition  of  the  patient  is  generally  improved 

by  the  administration  of  hyoseyamus.  I  generally  employ  Merck's 
hyoscyamine  in  solution  in  the  proportion  of  one  grain  of  the  alkaloid 
to  one  ounce  of  water.  ( )f  this  mixture,  four  drops  three  times  a  day, 
in   water,  after   meals,  may    be   given.      The  dose   should   gradually    he 

increased  by  the  addition  of  one  drop  a  day  until  the  toxic  effects  of 
the  drug  begin  to  be  perceived.  This  will  be  manifested  first  by  dry- 
ness of  the  throat.  When  this  condition  becomes  apparent,  the  dose 
should    lie  reduced   to  the  original  quantity,  ami    then    increased    as   in 


294  DISEASES   OF   THE   BRAIN. 

the  first  instance.  This  plan  of  procedure  should  be  repeated  sev- 
eral times. 

By  this  remedy  alone  the  tremor  is  often  markedly  diminished,  and 
the  paralysis  and  other  disorders  of  motility  and  sensibility  greatly 
lessened. 

Thus,  in  the  case  of  a  distinguished  gentleman,  a  Senator  of  the 
United  States,  who  consulted  me  in  the  spring  of  1870  for  what  was 
designated  shaking-palsy,  but  in  whom  I  diagnosticated  the  disease 
under  consideration,  amendment  was  perceived  from  the  very  first  day 
of  the  treatment.  The  tremor  and  paralysis  diminished,  the  mind 
became  stronger  and  more  able  to  endure  exertion,  and  the  physical 
strength  much  increased.  He  was  soon  able  to  write  and  to  attend  to 
his  official  duties,  and  he  has  continued  in  his  advanced  stage  of  im- 
provement to  the  present  date.  He  still,  however,  takes  his  medicines, 
and  will  probably  be  obliged  to  do  so  for  a  long  time  yet. 

In  another  case — that  of  a  gentleman  living  in  the  interior  of  this 
State — no  means  have  been  so  successful  in  improving  the  general 
health,  and  arresting  the  progress  of  the  disease,  as  the  preparation  of 
hyoscyamine  already  alluded  to.  I  have  given  this  remedy,  alone  or  in 
conjunction  with  others,  in  nine  cases,  and  never  without  a  decidedly 
favorable  effect. 

Electricity  is,  however,  a  powerful  adjunct,  and  I  always  employ 
it  when  the  opportunity  exists  for  so  doing.  The  primary  current, 
from  not  exceeding  fifteen  cells,  should  be  passed  through  the  brain 
antero-posteriorly  and  laterally,  as  previously  described,  and  the  sym- 
pathetic nerve  should  likewise  be  acted  upon  by  a  current  of  similar 
intensity. 

The  tremulous  muscles  should  also  be  subjected  to  the  influence  of 
a  primary  current  of  low  tension.  I  am  not  sure  that  it  makes  any  dif- 
ference in  which  direction  the  current  be  passed,  but  it  is  important 
that  it  should  not  be  so  intense  as  to  cause  any  considerable  pain. 

For  the  paralysis  the  induced  current — not  too  strong — is  to  be 
recommended,  and  for  any  contractions  that  may  be  present  it  is  the 
preferable  form  to  use. 

A  gentleman,  over  sixty  years  of  age,  from  Tennessee,  consulted 
me  in  September,  1870,  for  tremor  associated  with  paralysis.  His 
physician,  Dr.  W.  W.  Yandell,  came  with  him,  and  gave  me  much 
valuable  information  in  regard  to  the  progress  of  the  disease.  In  the 
first  place,  there  had  been,  several  years  previously,  symptoms  of  a 
disordered  cerebral  circulation,  indicated  by  pain  and  vertigo.  Soon 
afterward  tremor  supervened  in  the  left  hand,  and  gradually  extend- 
ed to  both  limbs  of  that  side.  There  were  also  paralysis  and  loss  of 
sensibility.  When  he  came  under  my  notice,  the  upper  extremity  was 
more  affected  than  the  lower  ;  contractions  had  taken  place,  and  the 
fingers  were  strongly  pressed  against  the  palm  of  the  hand,  the  hand 


PARALYSIS   AGITANS.  295 

was  bent  on  the  forearm,  and  the  elbow  was  flexed  to  its  utmost  ex- 
tent. The  limb  was  somewhat  atrophied,  but  electro-muscular  con- 
tractility was  not  sensibly  impaired. 

The  voice  was  exceedingly  weak,  but  there  was  no  paralysis  of 
the  tongue  or  facial  muscles,  and  though  the  patient  could  not  speak 
above  a  whisper,  every  word  was  articulated  distinctly,  and  was  ap- 
propriately used.  The  body  was  greatly  bent  forward,  the  attitude 
being  that  of  a  person  ascending  a  steep  hill,  and  there  was  decided 
festination.  The  tremor  and  paralysis  were  much  more  marked  on 
the  left  side  than  the  right,  and  the  agitation  was  altogether  inde- 
pendent of  voluntary  movements. 

The  mind,  except  as  regarded  the  memory,  was  not  essentially  im- 
paired, and  the  sight  and  hearing  were  unaffected  by  the  disease. 
There  had  never  been  any  convulsive  attack  or  loss  of  consciousness, 
and  the  course  of  the  disease  had  been  extremely  gradual.  Ophthal- 
moscopic examination  revealed  nothing  beyond  an  anaemic  condition 
of  the  retinae  and  choroids. 

I  diagnosticated  paralysis  agitans,  probably  involving  also  the  right 
corpus  striatum,  and  prescribed  the  tincture  of  hyoscyamus,  and  elec- 
tricity. The  patient  remained  in  New  York  a  few  days,  and  then  re- 
turned to  his  home  with  the  tremor  abated,  the  contractions  partially 
overcome,  the  muscles  improved  in  strength,  and  the  tendency  to  fes- 
tination  lessened. 

A  month  afterward  Dr.  Yandell,  who  had  continued  the  treat- 
ment, wrote  me,  of  the  patient,  that  the  improvement  was  more  de- 
cided than  his  most  sanguine  friends  had  anticipated,  and  still  con- 
tinued ;  that  the  agitation  was  scarcely  perceptible  ;  that  he  could 
more  than  half  extend  the  fingers  of  the  left  hand,  could  straighten 
his  wrist  and  elbow,  and  could  lift  a  chair,  or  put  on  his  hat,  with 
the  right  hand.  From  what  I  have  since  ascertained,  he  bids  fair  to 
recover  entirely. 

If  the  general  health  be  materially  impaired,  cod-liver  oil,  iron, 
and  strychnia,  may  be  administered  wit h  advantage. 

The  food  should  always  be  highly  nutritions,  and  a  glass  or  two  of 
wine,  if  not  particularly  contraindicated,  may  be  taken  daily  with  advan- 
tage. Passive  evercise  in  the  open  air  is  always  beneficial,  but  exces- 
sive walking  or  strong  muscular  exertion  of  any  kind  should  be  care- 
fully avoided.  Emotional  excitement  or  mental  labor  musl  be  rigidly 
avoided. 

Under  the  treatment   thus  indicated,  the  patient   may  at  least  be 

relieved  of  a  great  deal  of  his  suffering. 


296  DISEASES   OF   THE   BKAIN. 

CHAPTER   XIV. 

TVMOIiS  OF   THE  BRAIK 

TnouGH  tumors  of  the  brain  differ  greatly  in  character,  they  all, 
when  they  are  accompanied  by  any  notable  symptoms,  present  many 
features  in  common.  It  will  therefore  be  convenient  to  consider  them 
under  one  head,  and  point  out  their  differences  when  the  morbid  anat- 
omy and  pathology  are  discussed. 

Symptoms. — It  is  possible  for  a  person  to  have  a  tumor  of  the  brain 
as  large  as  an  orange,  and  present  no  symptoms  of  it  during  life.  One 
such  case  came  under  my  observation  several  years  ago,  and  many  oth- 
ers are  on  record.  In  the  instance  referred  to,  the  patient,  a  teamster, 
was  twice  shot  in  a  quarrel  ;  one  ball  grazed  the  skull,  ploughing  up  the 
right  parietal  bone  to  the  extent  of  an  inch  ;  the  other  entered  the  left 
breast,  wounding  the  heart.  Death  ensued  almost  instantly.  The  brain 
was  examined,  and  a  tumor  of  an  elliptical  form,  two  inches  in  its  long 
diameter  and  one  and  three-quarters  in  its  short  diameter,  was  found, 
involving  the  white  substance  of  the  left  posterior  lobe.  The  character 
was  that  which  Virchow  has  since  called  gliomatous,  and  contained  no 
nervous  tissue. 

Again,  it  sometimes  happens  that  tumors  of  large  size  exist  in  the 
brain,  and  produce  no  symptoms  till  a  few  days  before  death.  Then 
very  violent  manifestations  ensue,  and  the  patient  dies  convulsed  or 
comatose.  And  it  is  always  the  case  that  the  symptoms  are  entirely 
different,  as  one  or  other  part  of  the  brain  is  involved,  or  the  tumor  is 
large  or  small.  Thus,  we  know  very  well  that  a  morbid  growth,  seated 
in  the  pons  Varolii,  will  cause  very  diverse  symptoms  from  those  pro- 
duced by  a  similar  formation  in  one  of  the  anterior  lobes  of  either  of 
the  hemispheres.  We  may  say,  in  general  terms,  that  tumors  situated 
in  the  medulla  oblongata,  the  pons,  the  optic  thalami,  the  corpora 
striata,  the  crura  cerebri,  the  cerebellum,  and  the  convex  surface  of  the 
hemispheres,  give  rise  to  more  decided  manifestations  than  when  the 
white  substance  of  the  hemispheres  is  the  seat. 

Pain  is  probably  the  first  symptom  which  attracts  attention.  It  is 
generally  confined  to  a  definite  region  of  the  head  corresponding  to 
the  location  of  the  disease,  but  this  is  not  always  the  case.  It  may  be 
either  a  dull  ache,  lasting  the  greater  portion  of  the  day,  or  a  sharp, 
lancinating  paroxysm,  which  ensues  but  for  a  few  moments  and  re- 
curs frequently.  As  the  morbid  process  goes  on,  the  cephalalgia  be- 
comes more  severe,  and  finally  reaches  a  stage  of  great  intensity.  So 
great  is  the  suffering  that  the  patient  cries  out  with  agony,  and  in 
a  case  under  my  observation  suicide  was  attempted.  Mental  excite- 
ment, physical  exertion,  noises,  and  bright  lights,  aggravate  the  pain. 


TUMORS   OF   THE   BRAIN.  297 

The  special  senses  rarely  escape.  The  sight  is  among  the  first  to 
suffer  derangement.  Loss  of  sight  may  vary  from  slight  dimness  and 
narrowing  of  the  visual  field  to  complete  blindness  in  both  eyes.  A 
tumor  at  the  base  of  the  brain  which  involves  only  one  optic  nerve 
will  induce  progressive  blindness  in  the  eye  on  the  same  side  as  the 
lesion.  A  tumor  compressing  the  front  of  the  chiasm  will  destroy  the 
fibres  going  to  the  nasal  half  of  each  retina,  and  thus  produce  temporal 
hemianopsia  of  both  eyes.  If  the  optic  tract,  on  one  side,  back  of  the 
chiasm,  is  the  seat  of  a  tumor,  the  fibres  leading  to  the  temporal  half 
of  the  retina  on  the  same  side,  and  the  nasal  half  of  the  retina  on  the 
opposite  side,  will  be  destroyed,  thus  inducing  the  condition  known  as 
homonymous  hemianopsia. 

Cerebral  tumors  sometimes  result  in  blindness  simply  from  in- 
creased intra-eranial  pressure.  In  this  case  the  condition  known  as 
choked  disk  can  be  readily  demonstrated  by  means  of  the  ophthalmo- 
scope.    Choked  disk  is  always  followed  by  atrophy  of  the  optic  papilla. 

Affections  of  smell  and  hearing  are  of  much  less  frequent  occur- 
rence. Jacobi '  finds  that  in  a  total  of  five  hundred  and  fifty-four 
cases  of  brain  tumor,  hearing,  taste,  and  smell  were  only  affected  in 
sixty-seven,  or  twelve  per  cent.  "In  forty-six  out  ol*  these  sixty-seven 
cases  the  patients  suffered  from  either  tinnitus  or  deafness,  the  latter 
rarely  complete.  In  twenty-six  out  of  the  forty-six,  thus  in  more  than 
half  (fifty-six  per  cent.),  the  tumor  was  situated  in  the  cerebellum. 
This  fact  tends  to  confirm,  if  need  be,  the  recent  anatomical  demon- 
stration, which  traces  the  central  fibres  of  the  acoustic  nerve  to  the 
cerebellum."  Tumors  of  the  corpora  quadrigemina  also  produce  deaf* 
.  probably  on  account  of  their  proximity  to  the  auditory  trait  in 
the  tegmentum. 

Loss  of  the  Bense  of  smell  is  still  more  uncommon.  Tumors  situ- 
ated in  the  frontal  lobes  have  frequently  been  found  without  any  ab- 
normities of  the  Bense  of  smell  having  been  observed  during  the  life 
of  the  patient.  Tumors  in  this  region,  however,  have  been  known  to 
produce  anosmia,  usually  accompanied  by  seven'  and  continuous  frontal 
headache.  The  headache  in  these  cases  is  probably  due  to  the  press- 
me  exerted  upon  the  meninges. 

Disorders  of  sensibility  in  various  pari-  of  the  body  are  common. 

These   are  either  of   the    nature  of   heini-an:cst  hesia,   hyperast  he-ia,  or 

numbness  and  t  ingling. 

Henri-anaesthesia  may  or  may  not   accompany  hemiplegia.     It   i^ 

usually  the    result   of   a  growth    involving  the   posterior   portion  iA'  the 
internal  capsule,  and,  like   hemiplegia,  is  gradual  in    its  advancement. 

Pain,  numbness,  and  tingling  are  most  frequently  produced  bj  tumors 
situated  in  the  central  region  of  the  hemisphere. 

Vertigo  i-  a  very  general  symptom,  and  may  be  ><(  all  degrees  of 
'  "Hysteria  awl  Brain  Tumor,"  1888,  p.  1 1  I. 


298  DISEASES   OF   THE   BRAIN. 

intensity,  sometimes  preventing  the  patient  standing,  walking,  or  even 
sitting.  It  is  often  observed  very  early  in  the  course  of  the  disease, 
and  is  frequently  accompanied  by  nausea  or  vomiting. 

The  disorders  of  motility  are  shown  either  as  paralysis,  which 
may  or  may  not  be  accompanied  by  contractures,  or  as  mobile  spasms, 
including  convulsions,  localized  spasms,  tremor,  incoordination,  and 
choreiform  movements.  Paralysis  may  occur  either  as  hemiplegia,  in- 
volving the  leg,  the  arm,  and  the  lower  part  of  the  face,  or  it  may  be 
more  locally  confined  to  the  face,  to  an  arm,  or  to  a  leg,  or  the  face 
may  be  paralyzed  on  one  side  and  the  arm  and  leg  on  the  other,  or, 
more  rarely,  both  arms  or  both  legs  may  be  affected.  If  it  is  of  the 
hemiplegic  variety,  the  tumor  will  be  found  to  involve  either  the  in- 
ternal capsule,  the  crus,  or  the  pons  on  the  side  opposite  to  the  para- 
lyzed members.  Paralysis  of  the  face  and  arm,  or  of  the  arm  alone, 
or  of  the  leg  only,  usually  indicates  that  the  tumor  is  situated  in  or 
just  beneath  that  part  of  the  cortex  in  which  the  motor  centres  for 
the  face,  arm,  and  leg  are  respectively  situated. 

Crossed  paralysis — that  is,  paralysis  of  one  or  more  of  the  cranial 
nerves  on  one  side  and  paralysis  of  the  arm  and  leg  on  the  other  side — 
always  indicates  a  lesion  below  the  hemispheres  either  in  the  medulla, 
pons,  or  crus.  A  tumor  so  situated  as  to  involve  one  or  more  of  the 
cranial  nerves,  and  at  the  same  time  implicate  the  motor  tract  before 
it  decussates,  will  always  produce  crossed  paralysis. 

Bilateral  paralysis  of  both  arms  or  of  both  legs  can  only  occur  un- 
der two  conditions  :  either  there  are  two  tumors,  one  in  each  hemi- 
sphere, and  both  involving  the  same  part  of  the  motor  tract  in  their 
respective  hemispheres,  or  there  is  a  single  tumor  so  situated  as  to 
compress  both  motor  tracts.  In  the  first  case  the  tumors  are  usually 
found  in  the  hemispheres  in  the  vicinity  of  the  internal  capsule.  In 
the  second  case  the  tumor  will  be  found  lower  down,  either  on  the 
surface  of  the  brain  between  the  two  cerebral  peduncles,  and  thereby 
compressing  both  of  them,  or  else  in  the  mesial  line  of  the  pons.  In 
whatever  form  the  paralysis  may  appear,  it  is  almost  always  of  slow 
progress.  This  is  an  important  factor  in  distinguishing  brain  tumors 
from  cerebral  haemorrhage. 

Contractures,  muscular  rigidity,  accompanied  by  exaggerated  re- 
flexes and  by  clonus,  sometimes  follow  the  paralysis  or  keep  pace  with 
it.  "When  these  symptoms  are  observed  it  indicates  the  gradual  de- 
struction and  descending  defeneration  of  the  motor  tract. 

Tumors  of  various  degrees,  athetoid  and  choreic  spasms,  and  in- 
coordinate and  ataxic  movements,  are  sometimes  observed.  The  pres- 
ence of  these  different  forms  of  mobile  spasm  is  not  a  characteristic 
of  brain  tumor  alone  ;  they  are  seen  in  several  other  affections,  and 
depend,  in  my  opinion,  upon  the  irritation  of  nerve-cells  either  in  the 
cortex,  the  thalamus,  the  striatum,  or  in  the  cell  area  of  the  pons. 


TUMORS   OF   THE   BRAIN.  299 

Convulsions  are  other  prominent  symptoms,  and  they  may  be 
among  the  initial  phenomena.  It  is  not  at  all  unusual  for  the  first 
evidence  of  intra-cranial  disturbance  to  be  an  epileptiform  convul- 
sion, and  similar  paroxysms  may  occur  at  intervals  for  many  years. 
They  may  be  general,  or,  what  is  more  common,  limited  to  one 
side  of  the  body,  or  they  may  be  localized  in  either  extremity  or  in 
the  face. 

Ordinary  epileptic  convulsions  are  only  of  significance  as  an  indi- 
cation of  general  cerebral  irritation,  but  where  the  convulsive  move- 
ments are  limited  to  one  extremity,  or  to  a  part  of  one  extremity,  the 
exact  situation  of  the  seat  of  irritation  can  be  more  concisely  deter- 
mined. Thus,  if  the  convulsion  is  limited  to  the  hand  or  to  the  arm, 
the  tumor  can,  with  almost  absolute  certainty,  be  located  in  or  just 
beneath  that  part  of  the  cortex  where  the  motor  centres  for  the  hand 
and  arm  are  situated.  This  has  been  successfully  attempted  in  a  num- 
ber of  instances,  and  the  tumor  has  been  removed. 

Sometimes  consciousness  is  not  lost,  but  there  are  various  convulsive 
movements  of  the  limbs,  tonic  or  clonic  in  character.  Occasionally 
these  are  confined  to  the  muscles  of  the  face  or  eyeball. 

Disturbances  of  equilibrium,  manifested  by  tendency  to  advance,  to 
go  backward,  or  to  turn  round  to  the  right  or  left,  are  sometimes  present. 

With  these  symptoms  there  are  generally  others  not  so  palpably 
connected  with  the  morbid  intra-cranial  process.  Thus  there  may  be 
disorders  of  the  stomach,  bowels,  and  kidneys,  and  of  the  respiration 
and  circulation,  which  add  much  to  the  discomfort  of  the  patient. 

As  to  the  intellectual  faculties,  it  is  not  uncommon  to  find  that 
they  do  not  become  involved  to  any  considerable  extent  till  a  late  pe- 
riod of  the  disease.  Then  the  change  is  usually  a  gradually-advancing 
imbecility. 

Death  takes  place  either  by  convulsions  or  coma,  or  a  combination 
of  both.  The  following  cases,  which  I  select  from  my  note-book,  are 
interesting  in  several  relations: 

J.  H.,  male,  aged  thirty-seven,  came  under  my  observation  January 
15,  1856,  at  Fort  Riley,  in  Kansas.  A  few  months  before  ho  had  re- 
ceived an  injury  of  the  left  hip  by  being  thrown  from  his  horse,  and 
was  stunned  for  a  few  minutes.  A  few  days  afterward,  as  he  was  lying 
in  bed,  he  suddenly  became  vertiginous,  and  at  tho  same  time  had 
noises  in  his  ears  and  some  pain  not  very  definitely  located,  lie  never 
had  vertigo  again,  bat  the  pain  never  left  him  night  or  day  for  several 
weeks.  It  then  suddenly  ceased,  and  did  not  recur  till  the  morning  of 
December  31st,  when  a  sharp  twinge  was  experienced  in  the  front  of 
the  head,  and  lie  immediately  saw  every  thing  double.  Ptosis  and 
dilated  pupil  of  the  left  eye  soon  supervened,  and  the  arm  of  tho  right 
side  became  weaker.  When  I  saw  him  the  grasp  of  bis  hand  was  very 
feeble,  and  the  ocular  troubles  very  noticeable.     The   pain  was  almost 


300  DISEASES  OF   THE   BRAIN. 

constantly  present,  and  was  of  the  most  intense  character.     He  said  it 
seemed  as  if  a  red-hot  iron  were  being  thrust  through  his  brain. 

lie  had  come  several  miles  to  see  me,  and  went  home  after  I  had 
given  him  a  palliative  medicine.  A  few  days  afterward  a  messenger 
came  for  me  in  great  haste,  with  the  information  that  the  patient  was 
dying,  and  requesting  my  attendance.  On  my  arrival,  I  found  that  he 
had  been  dead  several  hours,  having  had  repeated  severe  convulsions. 
On  post-mortem  examination,  a  tumor,  spheroidal  in  shape,  with  an 
average  diameter  of  an  inch  and  a  quarter;  was  found  occupying  the 
middle  third  of  the  inner  surface  of  the  left  middle  lobe,  so  as  to  press 
on  the  left  crus  and  third  nerve. 

The  points  of  interest  in  this  case  are  the  sudden  cessation  of  the 
pain  and  its  recurrence  simultaneously  with  the  paralysis  of  the  third 
nerve,  the  slight  paralysis  of  the  body,  and  the  absence  of  convulsions 
till  just  before  the  fatal  termination.  The  ptosis,  diplopia,  and  dilata- 
tion of  the  pupil,  doubtless  occurred  at  the  very  instant  that  the  tumor 
encroached  on  the  crus. 

The  history  of  the  following  case,  which  I  saw  in  September,  1864. 
at  the  request  of  my  friend  Prof.  Van  Buren,  I  take  from  the  report 
of  Dr.  F.  N.  Otis,1  under  whose  immediate  care  the  patient  was  : 

Miss  E.,  aged  twenty-six,  was  of  healthy  parentage,  and,  though 
of  delicate  organization,  had  enjoyed  good  health  up  to  February,  1861, 
when  she  received  a  fall  on  the  ice,  striking  violently  upon  her  elbow. 
She  was  not  conscious  of  receiving  any  other  injury  at  the  time.  At 
3  A.  M.  of  the  following  day  she  awoke  with  an  intense  pain  in  the 
top  of  her  head,  of  a  throbbing,  lancinating  character,  which  continued 
throughout  the  day.  By  night  she  obtained  relief.  No  further  effect 
from  the  fall  was  experienced  until  about  two  weeks  subsequently,  when 
she  discovered  a  small,  firm,  circumscribed  swelling  on  the  crown  of  the 
head  at  the  point  where  the  pain  had  previously  been  felt.  This  swell- 
ing, which  was  painless,  increased  gradually,  until,  after  a  year,  it  had 
attained  the  size  of  half  a  lemon.  Soon  after  the  appearance  of  the 
tumor,  Miss  E.  began  to  suffer  with  severe  pain,  confined  chiefly  to  the 
vertex,  of  the  same  character  as  that  experienced  immediately  after 
the  fall.  This  pain  would  continue  almost  without  cessation  for  two 
or  three  weeks,  after  which  for  a  like  period  she  would  be  quite  free 
from  it. 

She  had  also  occasional  attacks  of  numbness,  preceded  by  great 
drowsiness,  and  a  cold,  creeping  sensation,  succeeded  by  total  loss  of 
the  power  of  motion,  sometimes  confined  to  a  single  extremity,  and  at 
others  involving  the  entire  body.  These  attacks  usually  came  on  at 
night,  or  after  rest  in  a  recumbent  position,  and  generally,  though  not 
invariably,  were  precursors  of  severe  headache.  They  were  always  fol- 
lowed by  great  nervous  prostration.  At  first  rare,  they  increased  in 
1  New  York  Medical  Journal,  vol.  i.,  18G5,  p.  26. 


TUMORS   OF   THE   BRAIX. 


301 


frequency  as  the  tumor  enlarged,  so  that  hy  February,  1863,  she  was 
seldom  free  from  them  for  more  than  ten  or  twelve  days,  and  the  tumor 
had  doubled  in  size  within  the  year.  She  now  began  to  be  much  an- 
noyed by  tingling,  crawling  sensations  in  her  face  and  through  the  head 
after  any  unusual  exertion  in  writing,  reading,  or  singing,  but  rode 
daily  on  horseback  with  apparent  benefit.  As  time  passed,  she  had  fre- 
quent dizzy  turns,  with  nausea,  and  sudden  flashes  like  electric  shocks 
passing  over  the  entire  body,  lasting  only  for  an  instant,  but  leaving 
her  much  prostrated.  The  headache,  which  was  always  of  the  most 
agonizing  description,  came  to  be  referred  chiefly  to  the  tumor,  though 
often  associated  with  pain  through  the  temples  and  other  parts  of  the 
head.  The  muscles  of  the  neck  sometimes  became  rigid,  and  the  vision, 
as  well  as  the  sense  of  taste  and  smell,  often  became  very  imperfect 
and  continued  so  for  weeks.  Sometimes  the  power  of  speech  would 
be  lost,  but  she  always  retained  perfect  consciousness.  These  attacks 
rarely  lasted  more  than  an  hour  or  two. 

On  the  23d  of  October,  1804,  she  was  attacked  with  a  peritoneal 
inflammation,  from  the  effects  of  which  she  died  on  the  ninth  day  there- 
after. Leaving  out  the  details  of  the  post-mortem  examination  of 
other  parts  of  the  body,  we  find  that  an  incision  was  made  across  the 
vertex  from  ear  to  ear,  and  the  skin  dissected  from  the  tumor,  at  the 
apex  of  which  it  was  found  to  be  firmly  adherent.     The  calvarium  was 

Fig.  20. 


then  sawn  in   a   line  one   inch   above   the  orbital  margin  around  to  the 

occipital  protuberance  ;  the  hemispheres  of  the  cerebrum  were  then 

sliced,  and  the  whole  raised  at  the  same  time. 


302  DISEASES   OF   THE   BRAIN. 

On  removing  the  two  hemispheres,  which  were  adherent  above,  a 
tumor  one  and  a  quarter  inch  in  thickness  and  three  inches  in  diame- 
ter, of  a  dull  lemon-yellow  color,  a  little  softer  than  the  cerebral  sub- 
stance, and  separated  into  two  lateral  halves,  was  seen  springing  from 
the  central  surface  of  the  dura  mater.  This  intra-cranial  tumor  had 
insinuated  itself  into  the  sulci  between  the  convolutions,  and  the 
dura  mater  could  be  traced  between  it  and  the  bones.  The  situation 
of  the  tumor,  and  the  relation  to  the  exterior  growth,  are  shown  in 
the  accompanying  cut  (Fig.  20). 

The  microscopical  examination  by  Dr.  Gouley  gave  indications  that 
both  formations  were  encephaloid  in  character. 

Similar  cases  to  the  foregoing  have  been  reported  by  Mr.  Paget,1 
of  London,  and  by  the  late  Dr.  Isaacs,2  of  this  city.  It  will  be  noticed 
that,  in  the  case  just  cited,  there  were  neither  convulsions,  paralysis, 
anaesthesia,  mental  derangement,  nor  difficulties  of  speech.  When  I 
saw  the  young  lady,  not  long  before  her  death,  there  were  no  symptoms 
present  from  which  it  could  have  been  inferred  that  a  tumor  occupied 
any  part  of  the  intra-cranial  cavity. 

I.  R.,  a  general  officer  of  volunteers  during  the  late  war,  consulted 
me  in  the  spring  of  1870,  through  his  brother,  for  what  was  thought  to 
be  softening  of  the  brain.  The  patient  was  stout  and  well  made,  had 
no  difficulty  of  speech,  no  derangement  of  sensibility,  and  no  paralysis 
of  any  part  of  the  body.  His  senses  were  remarkably  acute.  His 
memory,  however,  was  almost  entirely  gone,  he  had  forgotten  the 
names  of  his  children,  did  not  even  know  what  city  he  was  in,  and 
could  not  tell  me  where  he  had  been  just  before  coming  to  see  me. 
Besides  this,  there  was  absolutely  nothing.  His  strength  was  enor- 
mous, and  his  grip  one  that  I  shall  not  readily  forget. 

His  previous  history  was  that  he  had  served  arduously  through  the 
war,  and  had,  on  being  mustered  out  of  service,  resumed  his  business 
as  a  lumber-merchant.  No  syphilitic  taint  could  be  discovered.  Six 
months  before  I  saw  him  he  had  been  suddenly  seized  with  an  epilep- 
tiform paroxysm  which  was  followed  by  agonizing  pain  in  the  head. 
A  second  convulsion  ensued  in  about  a  month  afterward,  the  pain  con- 
tinuing to  be  of  the  utmost  severity,  and  almost  without  intermission. 
There  was  a  third  attack,  and  then  the  pain  ceased  ;  but  the  failure  of 
memory  began  to  be  manifested  from  that  moment,  and  had  gradually 
been  becoming  more  pronounced. 

I  diagnosticated  a  tumor  involving  mainly  the  white  substance  of 
one  of  the  hemispheres,  situated  probably  in  the  posterior  lobe,  and 
not  affecting  the  motor  tract,  or  the  course  of  any  of  the  cranial  nerves. 
My  principal  reasons  for  not  regarding  the  lesion  as  softening  were  the 
absence  of  paralysis  or  even  paresis,  the  integrity  of  all  the  special 

1  "Surgical  rathology,"  London,  1853,  vol.  ii.,  p.  221. 

2  "Transactions  of  the  Medical  Society  of  the  State  of  New  York,"  1859. 


TUMORS   OF   THE   BRAIX.  303 

senses,  and  the  absolute  perfection  of  articulation.  At  the  same  time 
I  regarded  the  matter  as  extremely  doubtful,  and  I  cite  the  case  here 
merely  as  one  of  interest  in  which  the  disease  was  probably  a  tumor. 
The  patient  died  during  the  first  week  in  January  of  the  present  year 
(1871),  but  I  have  received  no  details  of  any  post-mortem  examination. 

In  May,  1870,  I  was  requested  by  Dr.  Hermann  Knapp  to  meet 
him  in  consultation  in  the  case  of  a  gentleman  suffering  from  a  cere- 
bral tumor.  The  morbid  growth  apparently  occupied  the  right  ante- 
rior lobe  of  the  brain,  and  involved  also  the  temporal  region  of  the 
skull  on  the  same  side.  The  sight  of  the  right  eye  was  destroyed,  and 
that  of  the  left  so  much  impaired  that  only  strong  lights  or  shadows 
could  be  distinguished.  The  lymphatic  glands  of  the  neck  were  very 
much  enlarged. 

The  pain  was  most  acute  night  and  day,  with  scarcely  an  intermis- 
sion. The  right  arm  was  numb  and  paralytic,  but  there  was  no  abso- 
lute paralysis  anywhere  except  in  the  ocular  muscles.  The  mind  was 
intact,  and  there  had  never  been  a  convulsion. 

Under  the  use  of  the  iodide  of  potassium  and  the  protiodide  of  mer- 
cury the  swelling  of  the  cranium  diminished,  the  swollen  lymphatic 
glands  were  reduced,  and  the  pain  almost  entirely  abolished.  I  saw 
him  several  times  afterward,  and,  when  I  discontinued  my  visits,  he 
was  doing  wonderfully  well.  Subsequently,  however,  there  was  a  re- 
turn of  the  symptoms,  and  death  ensued. 

There  was  no  history  of  syphilis  in  this  case. 

The  following  account  of  a  case,  in  which  there  was  a  tumor  of  the 
cerebellum,  I  have  from  my  friend  Prof.  Austin  Flint,  M.  D.: 

"  In  June,  1842,  I  was  present,  by  invitation  of  Dr.  James  P.  White, 
of  Buffalo,  at  the  autopsy  in  the  case  of  W.  R.,  aged  about  forty  years. 
I  noted  at  that  time  the  following  brief  account  of  the  history  as  stated 
by  Dr.  White,  the  attending  physician: 

"The  illness  was  dated  from  the  preceding  February  (five  months), 
but  he  had  previously  complained  of  pain  in  the  head,  and  lassitude. 
In  February  he  had  had  chills,  which  were  at  first  attributed  to  malaria. 
Subsequently  vomiting  was  a  prominent  symptom;  it  occurred  in  the 
morning  immediately  after  rising  from  bed.  Cephalalgia  was  a  fre- 
quent, not  a  constant,  symptom.  He  referred  the  pain  especially  to 
the  occiput.  In  April  he  left  Buffalo  to  visit  friends  in  Rochester.  He 
was  prostrated  by  the  journey,  and,  his  condition  now  being  alarming, 
he  returned  home.  Notwithstanding  the  treatment  adopted,  he  grad- 
ually failed,  and  died  June  \  I  h. 

"There  had  never  been  convulsions  nor  paralysis. 

" Post- mortcu i  "Examination. — The  body  was  considerably  emaci- 
ated. There  was  slight  opacity  of  the  arachnoid,  and  in  some  situations 
a  small  quantity  of  serum  was  effused  beneath  this  membrane.  The 
effusion  within  the  ventricles  was  somewhat  Lrrcater  than  usual.     W  ith 


304  DISEASES   OF   THE   BRAIN. 

these  exceptions,  there  were  no  morbid  appearances,  except  in  the  cere- 
bellum. Here  was  a  tumor  of  the  size  of  an  English  walnut.  It  was 
of  fine  consistence,  and  supposed  to  be  tuberculous.  There  was  no  ap- 
pearance of  inflammation  or  softening  of  the  cerebral  substance  around 
the  tumor,  which  was  situated  in  the  right  lobe  of  the  cerebellum. 

"  It  was  ascertained  in  this  case  that  the  venereal  appetite  had  been 
wanting  for  many  months  before  death.  I  recollect  that  Dr.  White 
informed  me  at  the  time  that  vertigo  was  -a  feature  in  this  case,  and 
that  it  induced  unsteadiness  in  the  voluntary  movements.  Dr.  White 
has  since  informed  me  that  his  recollection  is  now  distinct  as  regards 
this  point." 

Causes. — The  causes  of  cerebral  tumors  are  so  intimately  connected 
with  their  character  that  a  classification  becomes  at  once  necessary. 
Following  Jaccoud '  in  this  respect,  I  shall  divide  them  into  four  groups: 
the  vascular,  the  parasitic,  the  diathetic  or  constitutional,  and  the  acci- 
dental. Even  with  this  division  we  shall  find  that  our  knowledge  of 
their  etiology  is  not  extensive. 

Vascular  tumors  are  aneurisms  of  the  cerebral  arteries.  The  term 
does  not  include  the  capillary  aneurisms  of  Bouchard  and  Charcot,  re- 
ferred to  under  the  head  of  cerebral  haemorrhage,  but  applies  only  to 
dilatations  of  the  larger  arteries.  According  to  Gouguenheim,8  they 
are  more  common  between  the  ages  of  fifty  and  sixty  than  at  other 
periods  of  life,  though  cases  were  met  with  under  the  age  of  puberty. 
Tables  given  by  Durand3  are  to  the  same  effect,  as  is  likewise  the  ex- 
perience of  Lebert,4  Gull,6  and  others.  This  is  what  might  be  expected 
from  the  known  proclivity  of  the  arteries  to  disease  after  the  age  of 
fifty. 

Sex  appears  to  exert  but  little  influence,  though  aneurisms  of  the 
cerebral  arteries  seem  to  be  somewhat  more  frequent  with  men  than 
women. 

As  exciting  causes,  blows  on  the  head,  falls,  sudden  and  great  physi- 
cal exertion,  intense  emotion,  or  mental  labor,  embolism,  and  concentric 
hypertrophy  of  the  heart,  are  to  be  mentioned. 

Parasitic  tumors  are  caused  by  the  migration  of  the  embryos  of  the 
cysticercus  and  echinococcus  from  other  parts  of  the  body. 

Diathetic  tumors  are  either  cancerous,  tuberculous,  or  syphilitic  in 
character.  The  first  named  are  more  common  during  the  adult  period 
of  life  than  any  other,  though  they  are  met  with  at  all  ages.  Although 
women  are  more  subject  to  some  forms  of  cancerous  tumors  than  men, 
vet  in  the  brain  they  are  far  more  common  in  the  male  sex.     Of  forty- 

'  Op.  cit,  p.  247. 

*  "Des  tumeurs  anevrysmales  des  arteres  du  cerveau."    These  de  Paris,  1866,  p.  12. 

'  "  Des  anevrysmes  du  cerveau."     These  de  Paris,  18G8,  p.  87. 

4  "  Klinische  Wochenschrift,"  Berlin,  Nos.  20  to  42,  1866. 

■  "Guy'»  Hospital  Reports,"  third  series,  vol.  v.    1859,  p.  281,  ft  s<>q. 


TUMORS   OF   THE   BRAIN.  305 

eight  cases  studied  by  Lebert,  cancer  of  the  brain  was  primary  in  forty- 
five,  that  is,  made  its  first  appearance  in  this  organ. 

Ogle,1  of  twenty-five  cases  of  cerebral  cancer,  found  that  in  thirteen 
the  disease  was  confined  to  the  brain,  while,  on  the  other  hand,  contrary 
to  the  generally  received  opinion,  Dr.  Mackenzie  Bacon*  found  but  ten 
primary  cases  out  of  seventy-three. 

There  is  no  doubt  that  cancer  of  the  brain  is  sometimes  the  result  of 
traumatic  cause. 

Tuberculous  tumors  of  the  brain  are  generally  met  with  in  young 
children,  though  they  do  occur,  as  in  the  case  related  by  Dr.  Flint  just 
cited,  in  adults.  They  are  almost  always  secondary  to  similar  products 
in  the  lungs. 

Syphilitic  tumors  are,  of  course,  the  result  of  the  syphilitic  infection 
of  the  system. 

Accidental  tumors  may  be  caused  by  injuries,  as  was  probably  the 
case  in  one  of  the  instances  cited.  Jaccoud,  however,  expresses  the 
opinion  that  such  an  apparent  relation  is  purely  fortuitous,  and  that 
all  we  know  of  their  etiology  is  that  they  are  more  common  after  the 
age  of  forty  than  before  that  period. 

Diagnosis. — The  diagnosis  of  cerebral  tumors  is  sometimes  almost 
self-evident,  in  others  it  is  equally  impossible.  This  difference  is  due, 
not  only  to  the  various  situations  they  may  occupy,  but  also  to  their 
diverse  nature. 

The  presence  of  severe  pain  in  the  head  for  a  long  time  is  of  itself 
some  indication  of  the  existence  of  a  tumor  if  it  is  unaccompanied  by 
febrile  excitement.  Epileptiform  convulsions,  occurring  after  the  age 
of  forty,  should  excite  suspicion  that  their  cause  is  to  be  found  in  a  mor- 
bid growth  of  some  kind.  The  character  of  the  convulsive  seizures  will 
aid  us  in  forming  an  opinion  of  their  etiology.  When  produced  by  a 
tumor  they  are  generally  unilateral,  the  loss  of  consciousness  is  not  so 
complete,  and  there  is  rarely  subsequent  stupor.  The  diagnosis  from 
epilepsy  is  rendered  more  evident  by  the  fact  that,  in  tumor,  the  con- 
vulsions are  seldom  accompanied  by  mental  weakness,  and  never  by 
periods  of  actual  unconsciousness.  From  softening  the  distinction  osn 
be  made  without  much  difficulty  in  the  majority  of  cases.  The  acute 
pain,  the  integrity  of  the  mind,  and  the  absence  of  general  paresis,  will 
usually  suffice.  But  sometimes  the  discrimination  cannot  be  made,  for 
there  are  cases  of  tumors  in  which  then-  is  very  little  pain,  in  which  the 
mind  is  involved,  and  in  which  the  paralysis  is  not  very  strongly 
marked. 

The  occurrence  of  very  limited  paralysis  points  to  the  existence  of  I 
tumor,  rather  than  any  other  affeotion.  A  gentleman  is  now  under  my 
care,  who,  several  years  ago,  had  a  cerebral  hemorrhage,  from  which  he 

1  British  and  Fortign  Sfedieo-Chirurf/ir.i!  A".  nVir,  July,  1865,  p.  2-j:i 
»  "On  Primary  Oaneerofthe  Brain,"  London,  IE 
21 


306  DISEASES   OF   TIIE   BRAIN. 

was  rendered  hemiplegic.  He  regained  to  a  great  extent  his  mental 
and  physical  powers,  but  a  few  days  ago  suddenly  had  diplopia  from 
paralysis  of  the  external  rectus  muscle  of  the  left  eye,  by  which  internal 
strabismus  was  produced.  As  yet  there  have  been  no  other  head-symp- 
toms except  vertigo,  with  which  he  has  suffered  a  great  deal  in  the  last 
two  years,  and  which  was  excessive  when  the  diplopia  appeared.  In 
other  respects  the  health  is  good,  and  the  mind  gives  no  evidence  of  be- 
ing affected.  The  paralysis  of  the  external  rectus  is  on  the  same  side 
with  the  general  hemiplegia. 

In  my  opinion,  though  I  express  it,  of  course,  without  positiveness, 
there  is  an  aneurismal  tumor  pressing  upon  the  sixth  nerve  after  its 
emergence  from  the  medulla  oblongata,  and  probably  affecting  the  left 
internal  carotid  artery.  If  this  view  be  correct,  other  symptoms  will 
certainly  arise  ere  long.  These  will  probably  consist  in  the  more  exten- 
sive implication  of  cranial  nerves,  and  in  the  supervention  of  hemi- 
plegia.1 

The  diagnosis  of  the  character  of  the  tumor  is  of  interest,  and  some- 
times of  importance  with  a  view  to  the  prognosis. 

Aneurismal  tumors  are  more  common  in  persons  of  advanced  age 
than  in  the  young,  they  are  more  frequently  accompanied  by  vertigo, 
and  they  are  more  generally  indicated  by  paralysis  of  one  or  more  of 
the  cranial  nerves.     The  mental  symptoms  are  not  often  marked. 

Parasitical  tumors  usually  first  manifest  themselves  by  the  occur- 
rence of  epileptiform  convulsions,  and  the  mental  faculties  do  not  long 
remain  unaffected,  for  the  reason  that  such  products  are  more  common- 
ly seated  in  the  gray  substance  of  the  brain  than  in  the  white  tissue  or 
the  ganglia  at  the  base.  As  these  latter  generally  escape,  troubles  of 
motility  are  rare.  Diathetic  tumors  are  more  easily  recognized  than 
any  others,  for  the  reason  that  we  have  other  evidence  of  the  existence 
of  constitutional  infection  in  the  great  majority  of  cases.  As  regards 
cancer,  however,  this  aid  is  not  generally  afforded,  the  affection  being 
usually  primary,  and  not  producing  the  ordinary  indications  of  the  can- 
cerous cachexia.  But,  as  in  the  case  cited  in  full,  and  the  others  re- 
ferred to,  the  existence  of  an  external  tumor  is  some  indication,  in  con- 
nection with  head-symptoms,  that  there  is  a  corresponding  growth  with- 
in the  cranium. 

Tubercle  may  be  suspected  in  cases  presenting  the  symptoms  of 
cerebral  tumor,  when  there  are  indications  of  similar  deposits  in  the 
lungs  or  other  parts  of  the  body,  when  the  subject  exhibits  evidence  of 
possessing  the  tuberculous  diathesis,  or  when  the  history  shows  heredi- 
tary tendency 

In  a  patient  presenting  the  symptoms  of  a  tumor  of  the  brain,  its 
nature  may  safely  be  considered  syphilitic  if,  in  addition,  his  clinical 

1  This  patient  was  found  dead  in  the  water-closet  of  his  residence  shortly  after  tha 
foregoing  lines  were  written.     There  was  no  post-mortem  examination. 


TUMORS  OF  THE  BRAIN.  307 

history  shows  that  he  is  tainted  with  syphilis,  or  has,  at  some  former 
period,  suffered  from  it. 

In  regard  to  accidental  tumors  or  those  of  various  anatomical  char- 
acteristics, there  is  not  much  to  be  said  of  their  diagnosis.  There  are 
no  means  by  which  one  species  can  be  distinguished  from  another,  and 
no  positive  indications  which  can  enable  us  to  discriminate  them  from 
other  tumors,  except  by  the  way  of  exclusion. 

Prognosis. — Cerebral  tumors  almost  uniformly  lead  to  a  fatal  result, 
except  they  be  syphilitic  in  character.  In  these  latter  there  is  a  very 
considerable  prospect  of  recovery  if  the  proper  medical  treatment  be 
adopted  ;  and  aneurismal  tumors  of  the  brain  are  occasionally  sponta- 
neously cured,  and  are  perhaps  sometimes  amenable  to  treatment. 

Morbid  Anatomy  and  Pathology.—  Vascular  Tumors.— The  most 
common  seat  of  cerebral  aneurisms  is  the  basilar  artery,  and  they  are 
larger  here  than  when  any  other  vessel  is  affected.  Gouguenheim ' 
gives  the  following  table,  based  upon  sixty-eight  cases  : 

Basilar IV  cases. 

Middle  cerebral 14 

Internal  carotids 12 

Anterior  cerebral 8 

Posterior  communicating 5 

Cerebellar 4 

Anterior  communicating 2 

Posterior  cerebral 3 

Middle  meningeal 2 

Arterio-venous 2 

Cerebral  aneurisms  do  not  differ  in  any  essential  particular  from 
similar  formations  in  other  parts  of  the  body.  They  are,  however, 
smaller,  rarely  being  as  large  as  a  walnut,  and  generally  ranging  in  size 
from  that  of  a  cherry-stone  to  that  of  an  almond. 

Lebert  ascertained  that  they  were  more  frequently  mei  with  in  the 
arteries  of  the  left  side  of  the  brain  than  in  those  of  the  right.  Gou- 
guenheim  confirms  this  observation.  Thus  of  forty-one  oases  in  which 
the  side  was  determined,  twenty-seven  were  on  the  left,  and  fourteen 
on  the  right.  This  difference  is  doubtless,  in  part  at  Least,  due  to  the 
fact  that  one  of  the  causes  of  cerebral  aneurisms,  embolus,  is  more  com- 
mon on  the  left  side  than  on  the  right,  and  in  part  to  the  oiroumstanoe 
that,  the  lefl  common  oarotid  arising  directly  from  the  arch  of  the  aorta, 
the  blood  of  thai  Bide  has  a  greater  degree  of  tension  than  the  Mood  of 
the  ri-ht  ride,  and  henoe  presses  on  the  art. -rial  walls  with  more  force. 

In  a  very  interesting  paper,  Prof.  W.  R.  Smith"  calls  attention  to 

*0p.cit.,  p.  21. 

■  "Cerebral  Aneurism:  Repot*  of  the  Dublin  Pathological  Society."  Dublin  '.mar. 
Urly  Journal  of  Medioal  Soumtt,  NoTember,  1870,  p.  443. 


308 


DISEASES   OF   THE    Bit. I  IN. 


the  fact  that  aneurisms  of  the  encephalic  arteries  may  be  produced  by 
embolism.  The  following  figure,  which  I  take  from  his  memoir,  gives 
an  excellent  illustration  of  such  an  aneurism  in  the  left  middle  cerebral 
arterv  : 

Fig.  21. 


In  regard  to  the  post-mortem  examination  of  the  patient,  from  whom 
the  preparation  was  taken,  Prof.  Smith  says: 

"  Upon  tracing  the  left  middle  cerebral  artery  into  the  fissure  of 
Sylvius,  it  was  found  to  be  obstructed  (just  where  it  branches  into  twigs 
surrounding  the  island  of  Reil)  by  a  plug  of  fibrine  of  a  yellowish  color 
and  oblong  form,  fully  a  quarter  of  an  inch  in  length  and  about  the 
eighth  of  an  inch  in  breadth.  At  the  seat  of  obstruction  the  vessel 
was  dilated  into  an  oblong  tumor  half  an  inch  in  length  and  a  quarter 
of  an  inch  broad,  the  space  intervening  between  the  original  plug  and 
the  arterial  tunics  being  occupied  by  coagulated  blood." 

The  theory  sustained  by  Prof.  Smith  was,  as  he  freely  states,  first 
proposed  by  Dr.  Senhouse  Kirkes '  in  the  paper  to  which  I  have  already 
referred  under  the  head  of  embolism. 

The  idea  was  formerly  very  generally  entertained,  that  cerebral 
aneurisms  were  always  true,  that  is,  caused  by  the  uniform  dilatation 
of  all  the  coats  of  the  artery.  Hodgson*  sustained  this  view  on  the 
ground  that  the  tunics  of  the  encephalic  arteries  were  of  such  extreme 
tenuity  that  they  readily  dilated,  and  Albers,3  Crisp,4  Gull,6  and  others, 
held  similar  opinions,  but  the  recognition  of  the  fact  that  the  arteries 
of  the  brain  are  peculiarly  subject  to  disease  in  persons  advanced  in 
age,  and  the  researches  of  Lebert,  Virchow,  and  Kolliker,  go  to  show 
that  such  a  view  is  erroneous.  Three  other  kinds  are  known  to  exist: 
the  mixed  external,  in  which  the  interior  and  middle  coats  are  ruptured 
and  the  sac  is  formed  by  the  external  coat;  the  dissecting,  in  which 

1  "  Medico-Chirurgical  Transactions,"  vol.  xxxv.,  p.  852. 

9  "A  Treatise  on  the  Diseases  of  Arteries  and  Veins,"  London,  1815. 

3  "Memoire  sur  les  anerrysmes  du  cerveau  et  ses  meninges,"  Bonn,  1836. 

4  "A  Treatise  on  the  Structure,  Diseases,  and  Injuries  of  the  Blood-vessels/'  London, 
1847. 

5  "  Guy's  Hospital  Reports,"  1857. 


TUMORS   OF   THE   BRAIN.  309 

the  internal  tunic  is  ruptured  and  the  blood  is  to  a  certain  extent  forced 
between  the  layers  of  the  middle  tunic  ;  and  the  arterio-venous.  This 
latter  is  seated  in  the  cavernous  sinus,  and  is  produced  by  the  rupture 
of  a  small  carotid  aneurism,  or  it  is  the  result  of  wound  or  injury. 

Aneurismal  tumors  may  cause  death  either  by  the  pressure  which 
they  exert  on  important  parts  of  the  brain  or  by  the  giving  way  of  the 
sac  and  the  consequent  extravasation  of  blood,  producing  pressure  and 
disorganization. 

The  rupture  of  an  aneurismal  tumor  of  course  leads  to  the  sudden 
development  of  a  new  set  of  symptoms,  varying  in  character  according 
to  the  situation  of  the  disease  and  the  course  which  the  extravasated 
blood  has  taken.  The  extravasation  may  occur  between  the  membranes, 
or  into  the  substance  of  the  brain,  or  into  the  ventricles,  and  is  generally 
followed  by  sudden  death.  Occasionally,  however,  the  patient  survives 
to  undergo  a  second  rupture,  or  to  die  from  secondary  alterations  of.  the 
cerebral  tissue.  Lebert  has  reported  a  case  of  aneurism  of  the  basilar 
artery,  in  which  there  was  a  spontaneous  cure;  and  another  of  the  mid- 
dle cerebral  artery  is  cited  by  Durand '  on  the  authority  of  Bourneville 
and  Fremy.  The  process  in  such  cases  is  similar  to  that  which  occurs 
in  like  cases  in  the  extra-cranial  arteries;  the  blood  in  the  aneurismal 
sac  becomes  solidified,  the  arterial  canal  at  this  point  is  obliterated,  and 
the  circulation  is  carried  on  by  the  collateral  vessels. 

Parasitic  tumors  are  of  two  kinds,  those  produced  by  the  cysticer- 
cus  and  those  caused  by  the  echinococcus  or  hydatids.  The  former  are 
small,  scarcely  ever  being  larger  than  a  small  bean.  They  are  rarely 
encysted,  as  in  other  parts  of  the  body,  but  are  in  close  apposition  with 
the  brain-substance.  They  are  generally  met  with  in  numbers  ranging 
from  ten  to  twenty.  Cruveilhier a  reports  a  case  in  which  there  were 
over  one  hundred. 

They  are  found  in  all  parts  of  the  cerebrum  and  cerebellum;  fifty  of 
those  discovered  by  Cruveilhier,  in  the  case  just  cited,  were  in  the  cere- 
bellum. Generally  thoy  are  near  the  surface  of  the  brain — often  in  the 
pia  mater,  in  which  situation  they  press  upon  the  gray  matter,  and 
often  in  this  latter  substance.  When  situated  in  the  ventricles,  there 
is  less  impediment  to  the  growth  of  the  parasite,  and  hence  it  may  be- 
come developed  into  a  more  or  less  perfect  tape-worm. 

Cobbold' states  that  there  are  about  one  hundred  cases  on  record  of 
cysticerei  being  found  in  the  brain  after  death.  Of  these,  Qriesinger4 
reports  between  fifty  and  si\ty. 

Echinococci,  or  hydatids,  though  much  Larger  than  the  foregoing- 

1  Op.  <'/.,  p.  14. 

*  "Anatomic  pathologique  gin6rale,"  tome  LL,  p.  B8,  Paris,  I 

•  ''Entozoa:  An  [ntroduction  to  the  Stu.lv  of  Helminthology,  irith  Reference  morn 
particularly  to  the  [nternal  Parasltei  of  Man,"  London,  1884. 

* "  Gysticerken  and  Ihre  Diagnose,"  "Archrv  der  Beilkunde,"  1881 


310  DISEASES   OF   THE   BRAIN. 

described  parasites,  are  less  numerous.  Generally  there  is  only  one, 
and  rarely  are  there  two  cysts.  Each  cyst  may  contain  a  single  hy- 
datid, as  is  usually  the  case,  or  there  may  be  more  in  different  stages  of 
growth.  In  size,  the  cysts  vary  from  that  of  a  marble  to  that  of  an 
orange,  and  consist  of  a  vascular  membrane  inclosing  the  parasite. 

Of  one  hundred  and  thirty-three  cases  occurring  in  the  human  sub- 
ject and  analyzed  by  Cobbold,  sixteen  were  situated  in  the  brain.  All 
were  of  course  fatal. 

Both  of  these  species  of  parasitical  tumors  may  be  primary,  or  they 
may  be  accompanied  by  similar  growths  in  other  parts  of  the  body. 

Diathetic  tumors  are  either  cancerous,  tuberculous,  or  syphilitic. 

Cancer  may  affect  any  part  of  the  brain,  though  it  more  generally 
attacks  the  hemispheres,  the  cerebellum,  the  optic  thalami,  the  corpus 
striatum,  or  the  pons  Varolii.  It  may  begin  in  the  bones  of  the  crani- 
um, in  the  memh/anes,  or  in  the  brain  itself.  A  common  seat  is  the 
orbit.  According  to  Dr.  Mackenzie  Bacon,1  of  seventy -three  cases  of 
brain-tumors  occurring  in  the  London  hospitals  during  the  period  from 
1854  to  1863,  ten  were  cancerous.  Ladame,2  of  three  hundred  and 
thirty-nine  cases  of  cerebral  tumors,  collected  from  various  sources, 
found  that  sixty-seven  were  cancerous. 

The  dimensions  of  cancerous  tumors  are  very  variable.  Generally 
they  do  not  much  exceed  the  size  of  an  English  walnut,  though  they 
may  be  twice  as  large. 

Either  variety  of  cancer,  encephaloid,  scirrhous,  or  colloid,  may  have 
its  seat  in  the  brain.  Primitive  cancer  is  usually  single;  secondary, 
multiple.  In  a  case  reported  by  Dr.  Webber,3  of  Boston,  in  which 
there  was  a  preexisting  cancerous  tumor  of  the  vagina,  the  brain  was 
found  to  contain  several  deposits  of  cancerous  growths — one  quite 
large,  situated  in  the  left  hemisphere,  and  two  in  the  cerebellum. 

Ogle  4  has  shown  that  the  brain-substance  surrounding  the  cancer- 
ous growth  undergoes  softening.     Frequently  it  is  not  changed  at  all. 

The  tumor  itself  does  not  often  undergo  softening,  but  a  kind  of 
fatty  degeneration  and  atrophy  occur,  and  the  tissue  becomes  hard  and 
compact,  with  no  traces  of  blood-vessels  remaining. 

Tubercular  tumors  may  be  either  single  or  multiple.  In  the  former 
case,  they  are  often  as  large  as  a  cherry  ;  in  the  latter,  they  may  be  as 
small  as  a  grain  of  wheat.  Very  large  tubercular  tumors  result  from 
the  fusion  of  two  or  more  smaller  ones.  They  are  generally  seated  in 
the  hemispheres  or  cerebellum,  though  the  other  parts  of  the  encepha- 
ion  are  not  exempt.  They  are  the  most  frequently  met  with  of  all  the 
forms  of  cerebral  tumors. 

1  Op.  cit. 

s  "  Symptomatologie  und  Diagnostik  der  Hirngeschwiilste,"  Wiirzburg,  1 865. 

*  Journal  of  Psychological  Medicine,  vol.  iv.,  1870,  p.  569. 

»  Journal  of  Mental  Science,  1864,  p.  229. 


TUMORS  OF   THE   BRAIN.  311 

Syphilitic  tumors  or  gummata  are  in  general  seated  in  the  mem- 
branes, or  in  these  and  the  gray  matter  at  the  base  of  the  brain.  They 
are  very  rarely  entirely  confined  to  the  substance  of  the  brain,  and  are 
never  encysted.  They  are,  therefore,  not  distinctly  circumscribed,  but  the 
elements  of  which  they  are  composed  are  infiltrated  into  the  surround- 
ing brain-tissue.  In  size  they  vary,  rarely  being  as  large  as  a  walnut. 
Histologically  they  consist  of  nuclei  and  cells.  The  former  contain 
nucleoli  and  occupy  the  periphery  of  the  tumor,  while  the  cells  are 
found  mainly  in  the  centre.  Syphilitic  tumors  are  ordinarily  accompa- 
nied by  like  growths  in  other  parts  of  the  body,  especially  the  lungs 
and  liver. 

Accidental  Tumors. — Under  this  head  are  included  all  formations 
not  diathetic  or  vascular.  Among  them  are  the  Jibro-plastic  tumors, 
which  may  attain  to  the  size  of  an  orange,  and  which  are  generally 
growths  from  the  dura  mater  at  the  external  part  of  the  base  of  the 
cranium.  They  are  composed  of  fusiform  cells,  nuclei,  and  blood-ves- 
sels. They  are  of  variable  consistence,  sometimes  being  almost  fluid, 
and  at  others  gelatiniform  in  character. 

Under  the  name  of  glioma,  Virchow  described  a  cerebral  growth 
due  to  an  abnormal  development  of  the  neuroglia  or  connective  tissue 
of  the  brain.  They  are  more  generally  found  in  the  posterior  cerebral 
lobes,  and  may  attain  to  the  size  of  an  orange.  Usually  there  is  but 
one.  There  are  two  kinds  of  these  tumors,  one  soft,  being  about  the 
consistence  of  the  brain-substance,  the  other  much  harder.  They  con- 
sist of  cells  and  nuclei,  but  never  contain  any  of  the  nervous  elements. 
Cholesteatomata,  sometimes  called  pearly  tumors,  may  arise  from  the 
cranial  bones,  from  the  membranes,  or  from  the  brain  itself.  They 
rarely  attain  to  the  size  of  a  walnut,  and  are  generally  very  much 
smaller.  Histologically  they  consist  of  a  limiting  membrane  of  ex- 
treme tenuity,  the  contents  of  which  are  disposed  in  concentric  layers. 
These  strata  are  epidermic  cells  which  have  undergone  degeneration. 
There  are  no  vessels  either  in  the  envelope  or  the  contents,  which,  in 
addition  to  the  elements  just  mentioned,  consist  of  cholesterine  and 
st.  a i-ine. 

Virchow  '  has  applied  the  term  psammomata  to  tumors  composed  of 
<;erebral  sand.  The  most  common  seat  of  these  growths  is  the  parietal 
dura  mater  at  its  anterior  part.  They  are  of  firm  consistence  and  are 
rarely  Larger  than  a  cherry  ;  microscopically  they  are  seen  to  consist  of 
isolated  grains  of  carbonate  of  lime,  surrounded  by  concentric  layers 
of  epithelium  held  together  by  connective  tissue.  Similar  tumors  are 
met  witli  in  the  choroid  plexus  of  the  fourth  rerticle, 

in  addition  to  < li<  s«-  there  are  osseous  tumors  (exostoses),  growing 
from  the  cranial  bones,  ami  which  may  or  may  not  be  syphilitic,  lij>o- 
matous,  enchondromatmis,  mucotM,  melanotic,  anil  several  other  speci.s 

1  "  Pathologic  dei  tumours,*1  tome  ii.  Paris,  1869,  \<.  105. 


312  DISEASES   OF   THE   BRAIN. 

oi  tumors,  which  are  treated  of  fully  in  the  special  monographs  on  the 
subject,  but  which  need  not  detain  us  in  the  present  connection.1 

Two  bodies  cannot  occupy  the  same  space  at  the  same  time.  In  a 
state  of  health,  the  brain  so  nearly  fills  the  cranial  cavity  that  there  is 
barely  room  for  those  variations  in  the  amount  of  blood  and  ventricu- 
lar fluid  which  occur  within  the  normal  limits.  The  growth  of  a  tumor, 
therefore,  is  at  the  expense  of  the  brain.  As  the  former  increases  in 
size,  the  latter  diminishes,  and  hence  some  of  the  symptoms  resulting 
from  tumors  are  similar  to  those  which  follow  atrophy  or  sclerosis. 
Besides,  we  have  other  consequent  effects,  such  as  oedema,  congestion, 
anaemia,  haemorrhage,  inflammation,  or  softening. 

When  cerebral  tumors  press  upon  the  cranial  nerves  they  produce 
fatty  degeneration  and  atrophy.  This  effect  is  manifested  by  altera- 
tions of  sensibility  or  of  motility  in  the  parts  supplied  by  these  nerves. 
Jn  the  eyes,  however,  in  addition,  the  changes  can  be  seen  with  the 
ophthalmoscope.  They  consist  in  the  main  of  atrophy  of  the  optic- 
disk,  disappearance  of  the  vessels,  congestion  of  the  retina,  or  haemor- 
rhage, or  serous  infiltration  with  detachment.  As  Jaccoud  remarks, 
easily  appreciated  by  the  ophthalmoscope,  these  lesions  have  a  real  im- 
portance in  clinical  diagnosis. 

As  to  the  relation  between  the  symptoms  and  the  seat  of  the  lesion, 
the  principles  enunciated  under  the  head  of  cerebral  haemorrhage  are 
applicable  to  cerebral  tumors. 

Treatment. — An  English  surgeon,  Mr.  Coe,2  reports  the  case  of  a 
woman,  aged  fifty-five,  who  had  enjoyed  good  health  till  on  one  occa- 
sion she  had  an  altercation  with  her  husband,  during  which  she  was  ex- 
cited to  very  great  anger,  and  in  the  course  of  which  she  received  sev- 
eral severe  blows  on  the  head.  About  the  same  time  she  made  severe 
efforts  to  lift  some  heavy  burdens.  A  few  minutes  afterward  she  com- 
plained to  a  neighbor  of  a  violent  noise  in  her  head — a  sensation  which 
she  had  never  experienced  before.  She  compared  the  sound  to  that 
made  by  the  working  of  a  fire-engine,  and  said  that  it  was  heard  more 
distinctly  in  the  left  than  the  right  ear.  It  was  accompanied  by  a  con- 
tinuous roar  similar  to  that  of  distant  thunder,  and  this  was  apparently 
situated  at  the  superior  and  posterior  angle  of  the  right  parietal  bone. 

From  the  beginning  of  these  symptoms  she  had  not  been  able  to  lie 
down,  but  was  obliged  to  sleep  in  a  sitting  posture.  Her  dreams  be- 
came exceedingly  frightful,  and  she  often  awoke  starting  and  terrified. 

On  examination  nothing  abnormal  could  be  detected  in  the  region 
of  the  heart  or  great  vessels,  but  in  the  neck  a  strong  aneurismal  bruit, 

1  For  a  very  full  and  complete  essay  on  the  subject  of  Cerebral  Tumors,  the  reader 
i9  referred  to  Dr.  J.  W.  Ogle's  cases  illustrating  the  "  Formation  of  Morbid  Growths, 
Deposits.  Tumors,  Cysts,  etc.,  in  Connection  with  the  Brain  and  Spinal  Cord  and  tbcii 
Investing  Membranes,"  British  and  Foreign  Medico- Ckirurgical  Review,  1864— '65. 

a  Cited  by  Gouguenheim,  from  Association  Medical  Journal,  November.  185T.. 


TUMORS   OF   THE   BRAIN.  313 

synchronous  with  the  pulse,  was  discovered.  It  was  heard  distinctly 
over  the  who^e  surface  of  the  head,  but  was  louder  over  the  left  tem- 
poral bone.  On  compressing  the  right  common  carotid  artery,  no  effect 
was  produced  in  the  murmur,  but  pressure  on  the  left  common  carotid 
caused  it  to  cease  at  once.  There  was  slight  strabismus  of  the  left  eye, 
and  vision  was  not  so  perfect  in  this  eye  as  in  the  right.  The  hearing 
was  not  affected,  but  the  noise  in  the  head  was  so  great  that  it  over- 
powered the  sound  of  the  carriages  in  the  street. 

Mr.  Coe  diagnosticated  an  aneurism  of  the  left  internal  carotid 
artery  at  its  entrance  into  the  cavernous  sinus  immediately  after  its 
emergence  from  the  petrous  portion  of  the  temporal  bone. 

On  the  11th  of  December,  1851,  Mr.  Coe  ligated  the  left  common 
carotid  artery.  The  bruit  instantly  ceased,  but  a  soft  and  almost  con- 
tinuous murmur  succeeded,  and  could  be  distinctly  heard  on  applying 
the  stethoscope  to  a  point  just  above  the  left  ear. 

The  patient  kept  the  horizontal  position  for  five  hours  after  the 
operation.  On  the  13th  there  was  no  noise  in  the  head,  even  when  she 
concentrated  her  attention  in  the  effort  to  hear  it.  From  this  time  on- 
ward she  continued  to  improve,  and  the  bruit  was  never  heard  again. 

The  probability  of  this  case  being  one  of  cerebral  aneurism  is  of 
course  very  great,  and  the  result  leads  us  to  believe  that  such  tumors 
are  not  entirely  beyond  the  reach  of  remedial  measures.  So  far,  how- 
ever, as  other  tumors  of  the  brain  are  concerned,  there  is  no  treatment 
calculated  to  cure  the  patient,  unless  a  syphilitic  taint  can  be  ascer- 
tained to  exist.  It  is  well,  however,  even  when  there  are  no  positive 
indications  of  the  presence  of  such  a  diathesis,  to  act  upon  the  pre- 
sumption that  it  does  exist,  and  to  administer  mercury  in  some  form 
with  the  iodide  of  potassium.  By  adopting  this  principle,  I  have  sev- 
eral times  succeeded  in  curing  patients  who  exhibited  the  most  positive 
indications  of  suffering  from  tumor  of  the  brain.  One  very  remarkable 
case  was  that  of  a  gentleman  who  consulted  me  several  months  since 
for  ptosis,  double  vision,  dilatation  of  the  pupil,  vertigo,  and  cephalalgia. 
Tin'  opinion  was  expressed  by  other  physicians  that  there  was  a  cere- 
bral tumor,  and  I  entirely  accorded  with  the  view.  The  gentleman  had 
no  recollection  of  ever  having  had  a  chancre  of  any  kind,  but  I  never- 
theless administered  the  bichloride  of  mercury  and  iodide  of  potassium, 
according  to  the  following  formula:  Ji.  Hyd.  bichlor.  (corros.)  gr.  ij, 
potass.  Lodidi  3  v,  aquae  \  iv.  M.  ft.  sol.  Dose,  teaspoonful  three  times 
a  day.  At  the  next  visit  of  the  patient  he  remembered  that  when 
in  China,   several  years  previously,  he  had  contracted  a  chancre  fox 

which  he  v\;i^  treated.     I  continued  the  treatment,  < joining  il  with 

the  use  of  electricity  to  the  eye  so  as  to  act  upon  the  paralysed 
muscles,  and  had  the  satisfaction  t<>  see  a  gradual  but  steady  improve- 
ment take  place,  till  eventually  in  the  course  of  a  lew  weeks  the  cure 
".as  complete. 


314  DISEASES   OF  THE   BRAIN. 

Another  case  was  that  of  a  lady  who  consulted  me  in  July,  1870, 
for  agonizing  pain  in  the  head,  vertigo,  and  paralysis  of  the  third  nerve 
of  the  left  side,  the  latter  producing  ptosis,  external  strabismus,  and 
consequent  diplopia.  I  could  discover  no  evidence  of  syphilis,  but  1 
nevertheless  administered  the  bichloride  of  mercury  and  the  iodide  of 
potassium,  as  in  the  foregoing  case.  The  induced  or  faradaic  current 
was  applied  to  the  eye,  and  the  patient  soon  began  to  mend.  The 
headache  disappeared  first,  then  the  vertigo,  and  eventually  the  paraly- 
sis. Subsequently  I  ascertained  from  the  lady's  husband  that  it  was 
barely  possible  he  might  have  infected  his  wife.  I  have  no  doubt  what- 
ever that  he  did. 

The  medication  recommended  can  do  no  harm.  There  is,  therefore, 
no  reason  why  the  patient  should  not  have  the  chance  of  being  benefited 
by  it. 

The  prescription  mentioned  is  a  very  eligible  form  for  administering 
both  the  mercury  and  iodide  of  potassium.  Salivation  is  never  caused 
by  it,  and  the  stomach  generally  tolerates  it  well.  Of  course  the  pro- 
portions of  the  ingredients  can  be  altered,  as  may  seem  best  in  individ- 
ual cases. 

The  induced  galvanic  current  is  beneficial  in  restoring  contractility 
to  the  paralyzed  muscles.  When  applied  to  the  eye  the  lids  should  be 
closed,  one  electrode,  a  wet  sponge,  is  placed  on  them,  the  other  is  held 
in  the  hand  or  placed  on  the  nape  of  the  neck,  and  a  current  not  so 
strong  as  to  cause  any  considerable  pain  is  then  allowed  to  pass  through 
the  intervening  tissues.  For  the  relief  of  the  pain  attendant  on  cere- 
bral tumors,  morphia  may  be  administered  hypodermically,  or,  what  I 
have  found  advantageous  in  several  cases,  the  extract  of  Indian  hemp, 
as  recommended  by  Reynolds,  may  be  used. 

Counter-irritation,  as  produced  by  the  actual  cautery  or  other  less 
powerful  means,  can  do  no  possible  good,  and  only  adds  to  the  discom- 
fort of  the  patient. 

Where  a  diagnosis  of  a  cortical  or  subcortical  tumor  can  be  made, 
recovery  may  be  hoped  for  in  a  fair  proportion  of  cases  if  operative 
measures  are  resorted  to  promptly.  The  death-rate,  as  a  direct  result 
of  the  operation,  is  small  when  the  serious  nature  of  the  operation  is 
taken  into  consideration.  In  sixty-three  cases  of  cerebral  growths  of 
various  kinds,  tabulated  by  Park,1  only  five  deaths  could  be  laid  to  the 
operation  itself.  In  regard  to  the  ultimate  recovery  from  the  epilepsy 
in  cases  of  cortical  and  subcortical  tumors,  it  can  only  be  said  that  the 
prognosis  is  fairly  good.  Several  cases  have  been  reported  as  cured, 
when  time  has  shown  that  the  report  was  not  justified  by  the  subse- 
quent return  of  the  convulsions.  Nevertheless,  the  statistics  show  that 
in  fully  fifty  per  centum  of  the  cases  operated  upon  either  great  im- 
provement or  complete  recovery  results. 

1  "Surgery  of  the  Brain."     Trans.  Cong.  Am.  Phi/s.  and  Surg.,  vol.  i.,  1888. 


ATHETOSIS.  315 

CHAPTER   XV. 

A  THETOSIS. 

TJxder  the  name  of  athetosis  ('A0eTos,  without  fixed  position)  I 
propose  to  describe  an  affection  which,  so-far  as  I  know,  had  not,  pre- 
vious to  the  publication  of  the  first  edition  of  this  work  in  1871,  at- 
tracted the  attention  of  medical  writers,  and  of  which  several  cases 
have  come  to  my  knowledge.  It  is  mainly  characterized  by  an  inability 
to  retain  the  fingers  and  toes  in  any  position  in  which  they  may  be 
placed,  and  by  their  continual  motion.  From  these  phenomena,  I  have 
applied  the  term  athetosis  to  the  disease,  having  as  yet  had  no  oppor- 
tunity of  ascertaining  by  post-mortem  examination  the  nature  of  the 
lesion  to  which  the  symptoms  are  due. 

Since  then  the  disease  has  been  admitted  to  be  well  founded  by 
several  eminent  pathologists,  among  them  Dr.  Clifford  Allbutt,1  Dr. 
Gairdner,2  Dr.  Clay  Shaw,3  Dr.  C.  C.  Ritchie,1  Dr.  Eulenburg,5  and 
Dr.  Sydney  Ringer.8  It  has  also  been  studied  by  MM.  Charcot,7 
Gairdner,8  Oulmont,9  Landouzy,"  Grasset,11  and  Brousse,12  in  France, 
Bernhardt,13  in  Germany,  and  others  in  Europe  and  this  country. 

These  symptoms  will  be  evident  from  the  following  histories  : 

J.  P.  R.,  aged  thirty-three,  a  native  of  Holland,  consulted  me  Sep- 
tember  13,  18G9.  His  occupation  was  bookbinding,  and  he  had  the 
reputation,  previous  to  his  present  illness,  of  being  a  first-class  work- 
man. He  was  of  intemperate  habits.  In  I860  he  had  an  epileptic 
paroxysm,  and,  since  that  time  to  the  date  of  his  first  visit  to  me,  had 
had  a  fit  about  once  in  every  six  weeks.  In  18G5  he  had  an  attack  of 
delirium  tremens,  and  for  six  weeks  thereafter  was  unconscious,  being 

1  "Cases  of  Athetosis,''  Medical  Times  and  Gazette,  January  27,  187S. 
'  I'ited  by  Dr.  Clay  Shaw,  who  gives  no  reference,  and  I  have  been  unable  to  find  the 
original. 

3  "  On  Athetosis  ;  or,  Imbecility  with  Ataxia,"  "  St.  Bartholomew's  Hospital  Reports," 
vol.  jx.,  1873,  p.  130. 

4  ".Vote  on  a  Case  of  Athetosis,"  Medical  Times  and  Qagette,  March  28,  1872. 

1  "Athetosis,"  Ziemsscn'a  "Handbuoh  der  spcciellen  Pathologic  and  Therapie,"  ew61f- 
tcr  Band,  "Krankheiten  des  NerrensyBteniB,"  II.,  sweite  lliilftc,  1875,  p.  889. 

"  "Notes  "ii  a  Case  of  Athetosis,  preceded  by  Bemiplegfe  and  BsBmiansestheaia,  and 
accompanied  by  Unilateral  Sweating,"  Practitioner,  August,   L877.     Also,'** Notes  of  a 
Post-mortem  Examination  In  ■  Case  of  Athetosis,"  Practitioner,  September,  1879. 
■  De  I'Athetoae,"  /.<;•<<//.•<  sur  let  maladiet  du  tyetemt  nerveuz.     Paris,  1S77. 

I  "  A  <';!-,■  of  Bammond's  Ath<  tosis,"  etc.,  Lancet,  June  '.',  is77. 
*  "Etudes  cliniques  sur  I'athetose,"  Thin  de  Parie,  1878. 

'""Note  but  mi  eat  d'athetose,"  eta,  Propria  Midical,  1878,  Nos,  5  and  6. 
"  "  Quatre  Boureaux  cai  d'athetose,"  eta,  Montpellier,  l  - ,  9. 

II  MonipellierMhdical,  1  xwiv.,  Aoat  Septembre,  1*77. 
11  Virckow't  Archiv,  I!  hvii.,  II.  i. 


316  DISEASES   OF   THE   BRAIN. 

more  or  less  delirious  during  the  whole  period.  Soon  after  recov- 
ering his  intelligence  he  noticed  a  slight  sensation  of  numbness  in 
the  whole  of  the  right  upper  extremity,  and  in  the  toes  of  the  same 
side.  At  the  same  time  severe  pain  appeared  in  these  parts,  and 
complex  involuntary  movements  ensued  in  the  fingers  and  toes  of  the 
same  side. 

At  first  the  movements  of  the  fingers  were  to  some  extent  under 
the  control  of  his  will,  especially  when  this-  was  strongly  exerted,  and 
assisted  by  his  eyesight,  and  he  could,  by  placing  his  hand  behind 
him,  restrain  them  to  a  still  greater  degree.  He  soon,  however,  found 
that  his  labor  was  very  much  impeded,  and  he  had  gradually  been 
reduced,  from  time  to  time,  to  work  requiring  less  care  than  the  finish- 
ing, at  which  he  had  been  very  expert. 

The  right  forearm,  from  the  continual  action  of  the  muscles,  was 
much  larger  than  the  other  ;  and  the  muscles  were  hard  and  developed, 
like  those  of  a  gymnast. 

When  told  to  close  his  hand,  he  held  it  out  at  arm's  length,  clasped 
the  wrist  with  the  other  hand,  and  then,  exerting  all  his  power,  suc- 
ceeded, after  at  least  half  a  minute,  in  flexing  the  fingers,  but  instanta- 
neously they  opened  again  and  resumed  their  movements. 

I  treated  him  with  galvanism,  primary  and  induced,  for  four  months, 
without  notable  result.  His  fits  were,  however,  arrested  with  bromide 
of  potassium. 

His  memory  began  to  be  impaired  soon  after  his  attack  of  delirium 
tremens,  and  his  intellect  was  manifestly  weakened  when  I  first  saw  him. 

January  17,  1871,  at  my  suggestion,  he  attended  the  New  York 
State  Hospital  for  Diseases  of  the  Nervous  System,  when  the  following 
points,  which  I  cite  from  the  rejiort  of  Dr.  Cross,  the  Resident  Physi- 
cian, were  noted  : 

The  head  is  symmetrical,  but  is  peculiar  in  shape — the  posterior 
portion  rising  to  a  much  higher  point  than  the  anterior,  while  the  lat- 
ter slopes  downward  and  forward,  giving  the  cranium  the  form  of  that 
of  a  Flathead  Indian.  The  special  senses  are  normal.  The  intellect  is 
somewhat  impaired,  and  his  ideas  are  not  so  vivid  at  one  time  as  at 
another.  His  memory  is  much  enfeebled.  There  is  slight  tremor  of 
both  upper  extremities,  but  there  is  no  paralysis  of  any  part  of  his  body. 
There  are,  however,  involuntary  grotesque  muscular  movements  of  the 
fingers  and  toes  of  the  right  side,  and  these  are  not  those  of  simple 
flexion  and  extension,  but  of  more  complicated  form.  They  occur  not 
only  when  he  is  awake,  but  also  when  he  is  asleep,  and  are  only  re- 
strained by  certain  positions,  and  by  extraordinary  efforts  of  the  will. 
Thus,  those  of  the  fingers  are  arrested  when  the  wrist  is  firmly  grasped 
by  a  strong  hand,  or  when  it  is  less  forcibly  held  in  a  vertical  position. 
But  if  the  arm  be  extended  horizontally,  the  fingers  at  once  begin  their 
movements.     During  their  continuance  the  arm  is  hard  and  rigid,  and 


ATHETOSIS. 


317 


the  calf  of  the  leg  is  also  in  the  same  state  of  tonic  spasm  while  the 
toes  are  in  motion.  The  movements  are  somewhat  paroxysmal,  being 
worse  at  times  than  at  others.  During  the  remissions,  the  power  of  the 
will  over  the  muscles  is  more  effective  than  when  the  paroxysms  are  at 
their  height. 

Sensibility  to  touch,  pain,  tickling,  and  temperature  is  normal  in 
all  other  parts  of  the  body.  There  is  slight  tremulousness  of  the 
tongue,  but  no  difficulty  of  articulation.  There  are  no  oscillatory 
movements  of  the  eyeballs  (nystagmus). 

The  involuntary  contractions  of  the  fingers  and  toes  do  not  take 
place  quickly,  but  slowly,  apparently  as  if  with  deliberation,  and  with 
gieat  force.  The  numbness  and  pain  in  the  arm,  hand,  leg,  and  foot 
have  increased  in  proportion  to  the  increase  in  the  contractions. 

The  toes  are  not  involved  to  the  same  degree  as  the  fingers.  Posi- 
tion does  not,  however,  afford  the  same  relief  to  them  as  to  the  fingers, 
and  the  spasms  are  more  tonic  in  character.  The  muscular  develop- 
ment is  greater  in  the  right  arm  and  leg,  from  the  almost  continuous 
muscular  action.  The  toes  are  kept  restrained  to  some  extent  by  the 
boot,  but  as  soon  as  it  is  removed  they  become  flexed,  and  take  on  their 
peculiar  movements. 

When,  by  a  strong  effort  of  the  will,  he  succeeds  for  an  instant  in 
arresting  the  movements  in  the  hand,  the  little  finger  at  once  be- 
comes strongly  abducted,  the  third  finger  participates  to  some  ex- 
tent, the  second  finger  is  slightly  flexed,  the  index-finger  is  extended, 
and  the  thumb  is  extended  to  its  very  utmost.     These  are  the  posi- 


Fio.  22. 


tions   in   all   cases   in    which    lie  succeeds  in   quieting   the  actions,  and 
they   ar<-  well    shown    in   the  accompanying  woodcut    (Fig.  22),  taken 

from  a  photograph. 

On  account  of  the  severe  pain  in  the  whole  arm,  caused   by  the 
spa-ins  of  the  muscles,  the  patienl   is  at  times  unable  to  go  to  sleep 


318  DISEASES   OF   THE   BRAIN. 

until  quite  exhausted.  On  awaking,  however,  after  a  few  hours'  re- 
pose, although  the  actions  have  continued  during  his  sleep,  they  are 
not  so  severe  as  at  any  other  time  through  the  day  or  night.  This 
state  of  comparative  repose  lasts  for  about  half  an  hour. 

His  habits  are  bad.  He  boasts  that  he  has  often  drunk  as  many  as 
sixty  glasses  of  gin  in  a  day,  and  it  is  therefore  doubtful  whether  the 
tremulousness  observed  in  the  tongue  and  the  muscles  generally  is  the 
effect  of  the  disease,  or  of  drink,  or  of  botl>  combined.  I  have  never, 
however,  seen  him  drunk,  or  even  under  the  influence  of  liquor.  His 
mental  faculties  are  decidedly  more  obtuse  than  when  he  first  came 
under  my  observation. 

Under  the  use  of  the  primary  galvanic  current  to  his  brain,  spinal 
cord,  and  affected  muscles,  and  the  internal  use  of  chloride  of  barium, 
he  improved  for  a  short  time,  but  I  have  no  hope  of  any  permanent 
result  being  obtained.  His  epileptic  paroxysms  are  kept  down  with 
bromide  of  potassium. 

In  May,  1873,  on  the  occasion  of  reading  a  paper  on  athetosis  be- 
fore the  Medical  Library  and  Journal  Association.  I  brought  this 
patient  to  the  meeting  ;  and  at  the  meeting  of  the  American  Neuro- 
logical Association  in  this  city,  in  June  last,  I  again  showed  him  as 
the  case  on  which  I  had  based  my  description  of  the  disease.  At 
that  time  he  was  in  about  the  same  condition  as  when  he  first  came 
under  my  notice.1 

Since  then  the  patient  has  repeatedly  come  under  my  notice,  and 
thus  far  exhibits  no  material  change  in  his  condition,  except  as  regards 
his  mental  power.  This  is  decidedly  weakened.  The  epileptic  convul- 
sions still  continue,  though  they  are  not  so  frequent  as  they  once  were, 
and  are  readily  controlled  by  the  bromide  of  potassium,  or  sodium, 
when  he  can  be  induced  to  take  it  with  any  approach  to  constancy. 
The  muscles  of  the  affected  arm  and  hand  are  greatly  hypertrophied, 
and  he  occasionally  suffers  from  pains  in  both  right  extremities.  He 
informs  me  that  he  has  entirely  stopped  the  use  of  alcoholic  liquors. 

The  second  case  occurred  in  the  practice  of  Dr.  J.  C.  Hubbard,  of 
Ashtabula,  Ohio,  who  forwarded  to  me  the  following  excellent  report, 
dated  January  11,  1870,  and  two  photographs — one  full-length  on  a 
small  scale,  and  another,  from  which  the  woodcut,  Fig.  22,  has  been 
engraved  : 

"  H.  8.,  aged  thirty-nine  years,  a  farmer  by  occupation,  married. 
His  father  and  paternal  grandfather  were  free  drinkers  of  ardent 
spirits.  His  only  brother  died  of  phthisis  pulmonalis,  and  I  think  he 
inherits  a  tubercular  tendency  from  his  mother.  The  patient  is  short, 
muscular,  is  well  made,  and  has  always  had  good  health  till  about  eight 
years  ago,  when  he  had  several  attacks  of  headache,  followed  by  ver- 
tigo and  loss  of  power  to  maintain  the  upright  posture,  or  to  sit  in  a 

1  "  Transactions  of  the  American  Neurological  Association,"  vol.  i.,  1875,  p.  17. 


ATHETOSIS.  319 

chair.  After  falling,  he  lost  consciousness  for  a  few  moments.  He 
had  three  of  these  attacks  in  two  months. 

"  Three  years  after  the  last  one — being  five  years  and  a  half  ago — 
while  at  work  on  a  hot  day  in  the  open  air,  he  lost  consciousness  and 
fell  to  the  ground.  This  attack  was  more  severe  than  the  pi-eceding 
ones,  and  he  was  confined  to  his  bed  three  days.  The  headache  was 
very  severe,  and  continued  a  week  after  he  left  his  bed.  Aphasia  and 
the  incoordination  now  affecting  his  right  forearm  and  right  leg  were 
the  sequence  of  this  stroke.  His  powers  of  speech  were  gradually  re- 
established in  the  course  of  six  weeks,  but  the  impediment  to  normal 
voluntary  muscular  motion  has  remained  to  this  day. 

"In  June  last  (1869)  he  applied  to  me  for  relief  from  cephalalgia, 
pain  in  the  right  side  of  the  chest,  cough,  and  dyspnoea.  He  com- 
plained also  of  vertigo,  and  of  flashes  of  light  before  his  eyes.  II is 
memory  and  judgment  were  slightly  impaired,  and  he  was  gloomy  and 
irritable. 

"  His  utterance  of  most  words  was  perfect,  but  he  stammered  over 
at  least  one  word  in  each  sentence.  It  required  a  good  deal  of  effort 
for  him  to  connect  his  ideas  and  his  sentences.  He  stumbled  at  mono- 
syllabic words,  such  as  then,  to,  at,  and,  and  other  conjunctions,  but 
in  a  moment,  after  considerable  effort,  he  could  speak  these  words  and 
conjoin  his  sentences  correctly. 

"  On  examining  his  right  foot,  I  found  that  he  had  lost  the  norma] 
antagonizing  force  between  the  flexors  and  extensors  of  the  toes.  The 
toes  were  ordinarily  in  a  state  of  flexion,  so  as  to  present  their  ends  to 
the  floor.  He  could  restore  the  balance  in  muscular  action  by  a  strong 
effort  of  the  will,  pressing  at  the  same  time  the  sole  hard  upon  the 
ground,  and  drawing  the  foot  backward  a  little.  Soon,  however,  the 
extensors  would  he  wearied  by  their  extra  work,  and  the  toes  would 
resunie-their  abnormal  position.  The  foot  is  slightly  inverted  at  every 
step,  and  it  is  not  exactly  guided  by  the  will.  His  gait  is  awkward — 
the  foot  being  set  down  with  a  kind  of  pawing  motion,  as  in  talipes 
varus. 

••A    similar   incoordination   is  observable  in   the  righl   hand  and 

fingers.  He  cannot  Ilex  his  fingers  without  the  aid  <»f  the  opposite 
hand,  hut  when  it  is  elosed  tin-  grasp  is  as  Strong  as  ever.  By  an  in- 
tense action  of  the  will  he  can  keep  his  fisl   closed   tor  a    few    moments. 

till  the  apparently  tired  fiexors  give  way.     The  little  and  ring  fingers 

are  hul   partially  extended,  and  are  Strongly  abducted.      The   ahductor 

minimi  digiti  and  the  flexor  brevis  minimi  digiti  are  hypertrophied, 

firm,  hard,  and    in   a  state   of   contraction    most    of   the   time,   and   the 

affected  hand  measures  three-fourtha  of  an  inch  more  around  the  palm 
than  its  fellow.     Tactile  sensibility  is  as  perfeel   in  the  affeoted  Limbs 

as  in  the  others.      His  muscular  powers  are  good,  and  he  thinks  hecan 

walk  twenty-five  miles  without  injurious  fatigue.     The  temperature  of 


320  DISEASES   OF   THE   BRAIN. 

the  affected  limbs  is  slightly  lower  than  that  of  the  opposite  ones.  Has 
slight  headache  frequently,  generally  at  evening ;  sleep  relieves  it. 
He  sleeps  well  when  undisturbed  by  pains  in  his  limbs.  Tongue  clean 
and  tremulous.  Has  slow-moving  pains,  from  the  hand  and  foot  up 
to  the  body  ;  they  often  last  half  a  day,  and  are  worse  at  night.  Has 
no  pain,  tenderness,  or  feeling  of  weakness  in  any  part  of  the  spine. 

"He  had  no  systematic  treatment  till  last  June.  The  chest-symp- 
toms referred  to  were  owing  to  subacute  bronchitis.  A  seton  was  in- 
serted between  the  shoulders,  and  iodide  of  potassium  was  adminis- 
tered for  ten  days.  His  lungs  being  then  better,  phosphoric  acid, 
cerium,  cannabis  indica,  sulphate  of  quinine,  and  sulphate  of  iron  were 
given  till  the  first  of  December  following.  He  then  felt  so  much 
better  that  he  discontinued  the  medicines.  The  seton  continued  to 
discharge  till  the  date  of  this  communication  (January  11,  1870),  and 
he  presents  at  this  time  a  very  marked  improvement.  His  headache  is 
not  severe,  he  has  less  pain  in  his  limbs,  and  he  speaks  without  hesita- 
tion. By  a  strong  effort  of  the  will  he  can  close  his  hand  without 
assistance.  He  came  five  miles  on  foot,  in  a  driving  snow-storm,  to 
see  me  to-day." 

The  accompanying  woodcut  (Fig.  23)  is  from  one  of  Dr.  Hub- 
bard's photographs.  The  resemblance  to  the  condition  shown  in  Fig. 
22  is  very  striking,  and  the  histories  of  the  two  cases  are  so  nearly 

Fig.  23. 


identical,  in  regard  to  all  essential  points,  as  to  leave  no  doubt  that 
they  describe  instances  of  the  same  disease.  Dr.  Hubbard's  case  was, 
probably,  when  he  wrote  the  history,  in  a  more  advanced  state  than  is 
mine  at  the  present  time.  The  distortion  of  the  hand  is  certainly 
greater.  In  the  other  photograph,  which  is  indistinct,  the  toes  are 
seen  fully  flexed. 


ATHETOSIS.  321 

The  symptoms  of  athetosis  are  clearly  indicated  in  the  foregoing 
histories.  Both  cases  came  on  with  epileptic  paroxysms — a  feature 
accompanying  other  organic  diseases  of  the  brain  and  spinal  cord.  In 
both  there  are  similar  head-symptoms,  trcmulousness  of  the  tongue, 
numbness  on  the  affected  side,  pains  in  the  spasmodically  affected 
muscles,  and  especially  complex  movements  of  the  fingers  and  toes, 
with  a  tendency  to  distortion.     In  neither  case  is  there  any  paralysis. 

Cases  of  athetosis  have  now  been  reported  in  such  numbers  that 
further  details  in  regard  to  them  are  scarcely  necessary  in  this  place. 
Eight  in  all  have  occurred  in  my  own  experience,  and  will  be  fully 
considered  in  a  special  monograph  upon  the  subject. 

Morbid  Anatomy  and  Pathology. — The  view  is  generally  held 
that  athetosis  and  all  other  diseases  which  are  characterized  by  mo- 
bile spasm  are  due  to  a  lesion  involving  the  cerebral  motor  pro- 
jection tract  in  some,  or  any,  part  of  its  course.  I  endeavored  to 
show,  a  few  years  ago,1  that  such  is  not  the  case  ;  that  where  the 
motor  conducting  fibres  are  implicated  by  a  lesion,  the  resulting 
spasm  is  spastic,  and  that  mobile  spasm  is  produced  by  the  irritation 
of  nerve-cells. 

The  lesions  which  have  been  discovered  in  every  case  of  athetosis 
in  which  an  autopsy  could  be  obtained  substantiate  this  view.  I 
have  been  enabled  to  collect  the  histories  of  thirteen  cases  of  athe- 
tosis, in  all  of  which  autopsies  were  obtained. 

The  first  case,  according  to  Brissaud,5  was  reported  by  Lauenstein. 
The  lesion  involved  the  posterior  part  of  one  thalamus. 

The  second  case  was  reported  by  Pick."  Here  also  the  lesion  was 
found  to  exist  in  the  posterior  portion  of  one  thalamus. 

Grassei  '  reported  the  third  case.  In  this  instance  there  wen1 
three  spots  of  softening — one  on  the  inferior  portion  of  the  thalamus, 
one  in  a  portion  of  the  caudate  nucleus,  and  one  in  the  lenticular 
nucleus. 

The  fourth  case  was  one  of  Richet's,  but  was  reported  by  Oul- 
inont.  Here  several  spots  of  softening  in  different  parts  of  the 
hemispheres  were  observed.  There  was  also  an  area  of  softening 
which  destroyed  almost  the  entire  posterior  portion  <>i'  the  caudate 

DUCleUS,  and  another  area   whieli    had    made   a   deep  cavity  in   the   len- 
ticular nucleus. 

Thr  fifth  ease  came  under  the  observation  of  Dr.  Fletcher  Beach.' 

The   microscope    revealed    an    increase    in    number   Of    the   vessels,    dis- 
tention of  many  of   them,  extensive  infiltration  of   the  tissue  with  leu- 

1  "  Athetosis,"  ■!•»<<■.  Nvrv.  Ment.  Dm., 
-  t;,,-:, it,  hebdomadairt,  1880,  p.  808. 
3  Proffer  VtertefjahrKhrifty  L879,  p.  111. 
1  Prog,  mi 'I ,  I'aii-,  November  L8,  1880. 
«  Brit, 
22 


322  DISEASES   OF  THE   BRAIN. 

oocytes,  especially  in  the  perivascular  sheaths  of  the  vessels,  and 
many  of  the  vessels  contained  clots.  These  changes  were  principal- 
ly in  the  cortex  of  the  inferior  parietal  lobule,  and  first  tempero- 
sphenoidal  convolution. 

In  the  sixth  case,  reported  by  Ringer,1  a  cyst  was  found  occupy- 
ino-  the  posterior  part  of  the  lenticular  nucleus,  and  involving  the 
white  matter  outside  and  beneath  the  thalamus  and  a  small  part  of 
the  thalamus  itself.  About  one-fifth  of  the  lenticular  nucleus  was 
destroyed,  together  with  a  few  fibres  of  the  internal  capsule. 

The  seventh  case  was  reported  by  Landouzy.2  The  autopsy  re- 
vealed a  focus  of  softening  in  the  lenticular  nucleus  on  the  left  side. 
In  the  centre  of  this  patch  of  softening  a  calculus  about  the  size  of  a 
bean  was  found. 

The  eighth  case  was  reported  by  Dr.  Murrell."  The  whole  right 
hemisphere  was  smaller  and  about  three-quartei-s  of  an  inch  shorter  than 
the  left  one.     Almost  the  entire  lenticular  nucleus  was  destroyed. 

The  ninth  case  was  reported  by  Emil  Denange.4  There  was  a 
lar£?e  spot  of  softening  on  the  cortex,  which  involved  all  that  portion 
of  the  ascending  parietal  convolution  in  which  Ferrier  locates  centres 
for  complex  movements  of  the  fingers  and  hand. 

The  tenth  case  is  particularly  interesting  from  the  fact  that  it  is 
the  report  on  the  autopsy  of  the  original  case  whose  history  is  related 
in  the  preceding  pages  of  this  chapter.  He  had  suffered  from  the 
disease  for  twenty-two  years.  The  athetoic  movements  involved  the 
right  foot  and  the  right  hand.  There  was  no  paralysis  ;  on  the  con- 
trary, the  muscles  of  the  forearm  and  leg  were  abnormally  developed. 
There  was,  however,  a  certain  amount  of  stiffness  and  rigidity  of  the 
muscles,  which  became  quite  apparent  when  he  attempted  to  walk  or 
to  use  his  arm.  Epileptic  convulsions  were  of  frequent  occurrence 
from  the  very  incipicncy  of  the  disease.  They  were  very  severe,  and 
sometimes  took  that  form  known  as  "double  consciousness."  In  one 
of  these  attacks  of  epilepsy  he  died.  The  brain  could  not  be  obtained 
till  forty-eight  hours  after  death.  There  was  nothing  suggestive  of 
any  pathological  abnormality  in  the  skull,  the  membranes,  or  the  sur- 
face of  the  brain. 

As  the  cerebral  substance  was  somewhat  softened,  the  hemispheres 
were  carefully  cut,  after  Binot's  method,  into  sections  of  about  half 
an  inch  in  thickness,  and  each  section  was  then  carefully  hardened  in 
Mailer's  fluid.  As  the  left  hemisphere  was  cut,  a  dense  hardened 
mass  was  encountered  in  the  region  of  the  basal  ganglia.  No  other 
gross  lesion  could  be  discovered.  When  the  sections  were  sufficiently 
hardened,  they  were  photographed,  and  were  then  sent  to  Dr.  E.  C. 
Spitzka  for  examination. 

'  Practitioner,  London,  September,  1879.  2  Projrh  med.,  1878,  Nos.  6  and  6. 

3  Lancet,  London,  1879,  i.,  369.  4  Revue  de  med.,  Paris,  May,  1883. 


^>    ^  (<;  K  <5  «^  s 


ATHETOSIS.  323 

Dr.  Spitzka's  report  is  as  follows:  "The  lesion  consists  of  a  firm 
resistent  fibrillar  connective-tissue  mass,  which,  both  at  the  anterior 
and  posterior  levels,  did  not  yield  to  the  knife,  but  came  out  bodily 
from  the  soft  (post-mortem  softened)  normal  tissue,  in  which  it  ap- 
peared to  have  been  loosely  imbedded.  It  extended  antero-posteriorly 
from  the  ventral  third  of  the  caudate  nucleus,  at  the  level  of  the  an- 
terior division  of  the  internal  capsule,  which  it  also  invaded,  directly 
backward  to  the  point  where  the  capsule  begins  to  collect  its  fibres 
to  form  the  crus,  at  about  the  level  of  the  mammillary  bodies,  here 
invading  the  thalamus  proper  (outer  nucleus  and  reticular  stratum 
of  same),  nearly  obliterating  the  subthalamic  region  (body  of  Luys 
and  zona  incerta),  extending  across  the  capsule  fibres,  and  encroach- 
ing on  the  inner  and  middle  articuli  of  the  lenticular  nucleus,  at  their 
attenuated  posterior  ends.  The  thalamus  and  subthalamic  regions  in 
their  aggregate  had  suffered  a  diminution  in  bulk  of  one  third  their 
mass,  which  was  noticeable  mostly  in  the  vertical  extent." 

The  accompanying  illustrations  (Fig.  24),  taken  from  drawings 
made  by  Dr.  Spitzka,  accurately  depict  the  situation  of  the  lesion. 

It  will  therefore  be  understood,  from  what  has  just  been  said,  that 
the  direct  motor  tract  in  the  internal  capsule  was  not  involved  to  any 
extent.  Lesions  which  affect  that  part  of  the  caudate  nucleus  which 
was  involved  in  this  case  have  not  been  accompanied  by  athetosis. 
The  probability  is,  therefore,  that  the  symptoms  observed  depended 
upon  the  situation  of  the  lesion  in  the  thalamus  and  in  the  subthalamic 
region.  In  the  following  case  the  thalamus  Mas  severely  injured,  while 
the  lesion  in  the  lenticular  nucleus  was  slight ;  and  in  the  twelfth  case 
the  corpus  striatum  was  not  affected  at  all. 

The  eleventh  case  was  reported  by  Dr.  E.  C.  Spitzka.'  In  this 
the  situation  of  the  lesion  corresponded  accurately  to  the  lesion 
in  my  own  ease — t hat  is,  the  posterior  part  of  the  thalamus,  the  pos- 
terior extremity  of  the  internal  capsule,  and  the  outer  part  of  the  len- 
ticular nucleus  were  diseased,  while  the  motor  tract  escaped  uninjured. 

The  twelfth  ease  was  reported  by  Dr.  E.  C.  Seguin,1  and  was 
described  by  him  us  a  ease  of  atheto-choreio  spasm  of  the  right  side  of 
the  body.  The  lesion  was  found  to  he  a  glioma  id'  the  left  thalamus 
ami  adjacent  internal  capsule. 

The   thirteenth    case    is   reported   by    ('onto.'1      In  this   instance   the 

athetosis  wras  limited  to  one  arm.     The  lesion  discovered  was  a  degen- 
eration "I  the  cortex  of  the  so-called  arm  centre. 

From  a  study  of  these  cases  it  will  be  observed  that  in  nol  a  single 
instance  was  the  lesion  confined  to  the  motor  tract.  On  the  contrary, 
w  I  let  her  the  motor  or  the  sensory  tract  wire  implicated  or  not,  in  every 

'  Meeting  of  the  American  Neurological  Association,  June  8, 

'•  Bra  il  .'/■</,  Rio  dc  Janeiro,  i  • 


324  DISEASES  OF  THE  BRAIN. 

case  either  the  cortex,  the  thalamus,  or  the  striatum  were  discovered 
to  be  diseased.  Lesions  of  the  direct  motor  tract,  between  the  cortex 
and  the  basal  ganglia,  such  as  abscesses,  tumors,  or  haemorrhages,  are 
not  of  infrequent  occurrence,  but  no  case  has  yet  been  reported  where 
such  a  lesion  has  been  followed  by  athetosis  or  any  other  form  of  mobile 
spasm.  Whore  the  motor  tract  is  implicated  there  will  be  hemiplegia, 
spastic  spasm,  and  exaggerated  reflexes  in  addition  to  the  athetosis. 
Where  the  sensory  tract  is  involved,  pain,  numbness,  tingling,  or  anaes- 
thesia will  accompany  the  athetosis.  In  all  of  these  cases,  however,  one 
or  both  of  the  basal  ganglia  or  the  cortical  motor  centres  were  diseased. 

Athetosis  cannot  be  attributed  to  disease  of  the  sensory  tract, 
because  in  many  instances  this  portion  of  the  brain  is  found  to  be 
perfectly  healthy. 

Since,  therefore,  brains  of  athetoic  patients  are  found  without  lesions 
of  the  motor  tract,  and  since  others  have  been  observed  without  lesions 
of  the  sensory  tract,  while  in  all  cases  one  or  both  of  the  basal  ganglia 
or' the  cerebral  motor  cortex  are  invariably  diseased,  there  is  only  one 
conclusion  to  be  reached,  and  that  is  that  athetosis  is  due  to  an  irrita- 
tive lesion  of  either  the  thalamus,  the  striatum,  or  the  motor  cortex. 

It  would  appear,  therefore,  that  athetosis  is  a  distinct  pathological 
entity. 

Relative  to  the  confounding  of  the  affection  with  post-hemiplegic 
chorea,  as  has  been  done  by  Charcot  and  others,  I  have  only  to  say 
that  the  distinction  between  the  two  conditions  is  as  well  marked  as 
between  chorea  and  disseminated  cerebro-spinal  sclei'osis.  In  athe- 
tosis the  movements  are  slow,  apparently  determinate,  systematic, 
and  uniform  ;  in  post-hemiplegic  chorea  they  are  irregular,  jerking, 
variable,  and  quick.  Moreover,  athetosis  is  not  by  any  means  neces- 
sarily post-hemiplegic.  In  the  original  case  there  had  never  been 
hemiplegia,  nor  was  there  such  a  state  in  the  second  case,  on  which 
my  description  of  the  disease  was  based.  Of  the  eight  cases  which 
have  occurred  in  my  experience,  hemiplegia  was  not  an  antecedent 
condition  in  four. 

Neither  is  it  necessarily  confined  to  one  side  of  the  body  ;  cases  of 
double  athetosis,  without  hemiplegia,  having  been  reported  by  Oul- 
mont '  and  Brousse,2  in  which  there  was  probably  general  cerebral 
atrophy. 

It  is  no  matter  for  surprise  that  many  of  the  cases  regarded  as 
being  athetosis  are  not  instances  of  that  affection.  This  is  certainly 
the  case  with  many  of  those  reported  by  Dr.  Clay  Shaw,  MM.  Grasset, 
Charcot,  and  others.  A  similar  event  took  place  when  aphasia  was 
first  prominently  brought  to  the  notice  of  the  medical  profession. 
Every  case  of  loss  or  impairment  of  the  faculty  of  speech,  whether 
from  paralysis  of  the  tongue  or  lips,  or  other  cause,  was  considered  by 

1  Op.  cit.  *  Op.  cit. 


CEREBRAL   SYPHILIS.  325 

some  authors  to  be  a  case  of  aphasia.  It  was  not  till  the  disease  be- 
came well  known  that  these  errors  ceased  to  be  made. 

Treatment. — From  the  nature  of  the  lesions  discovered  post-mor- 
tem, it  would  be  absurd  to  consider  any  medicinal  treatment  for  this 
disease.  There  is  one  means,  however,  of  alleviating  the  spasms  for  a 
long  time,  and  possibly  of  arresting  them  altogether.  This  effect  can 
be  produced  by  stretching  the  appropriate  nerves  in  the  limb  affected. 
Dr.  W.  J.  Morton '  was  the  first  to  perform  this  operation  for  this  dis- 
ease. In  his  case  such  force  was  used  as  to  render  the  limb  permanent- 
ly paralyzed.  I  performed  the  operation  three  times  on  the  patient 
whose  symptoms  led  me  to  describe  this  disease.  The  median  nerve  was 
stretched  in  each  instance.  After  every  operation  the  spasms  ceased 
entirely  in  both  arm  and  leg,  and  the  pain,  which  was  severe,  disap- 
peared. Complete  relief  was  obtained  after  the  first  operation  for  four 
months  ;  then  the  pain  and  athetosis  gradually  returned.  In  his  re- 
lieved condition  I  presented  him  before  the  New  York  Neurological 
Society.  After  an  interval  of  a  year  I  operated  for  the  second  time. 
Again  he  was  free  from  every  symptom  of  his  disease  for  four  months, 
and  it  was  fully  eight  months  before  the  disease  was  as  severe  as  it 
formerly  was.  After  the  third  operation  more  benefit  was  derived 
than  from  either  of  the  others.  For  eighteen  months  not  a  trace  of 
athetosis  was  visible.  He  could  use  his  hand  for  writing,  dressing  him- 
self, eating,  and  in  fact  for  almost  any  purpose.  The  muscles  of  the 
hand,  arm,  and  foot  were  perfectly  under  the  control  of  the  will. 

Griedenbnrg1  reports  a  case  which  was  operated  upon  by  Fricke. 
"The  median  nerve  was  stretched.  Immediately  after  the  opera- 
tion, and  on  the  following  day,  no  movements  were  noticed.  On  the 
second  day  after  the  operation  the  athetosis  reappeared,  and  on  the 
fourth  day  the  movements  had  regained  their  former  intensity."  It 
is  <|iiite  likely  that  subsequent  operations  would  have  been  attended 
with  longer  intervals  of  rest.  It  seems  to  me  that  nerve-stretching 
holds  out  the  only  hope  of  relief. 


CHAPTER  XVI. 

OKB  EBB.  i  I    8  YPHIl  IS. 


Although  the  relations  of  syphilis  to  diseases  of  the  brain  have 
been  considered  in  the  foregoing  chapters,  it  Beems  advisable  t"  treat 

the  snbjecl   with  more  particularity  under  its  own  special  head.      In  SO 

doing  I  shall  avail  myself  to  a  great  extent  of  the  excellent  epitome  of 

1  Journ.  Wen.  ,<„,/  Mertt.  Die.,  1882,  V  EL,  vii. 
'  \  lei  fcllc  \'>n  LthetOM,"  ft.  Petersburg  med.  Woeh  ,  1882,  vii. 


326  DISEASES  OF  THE  BRAIN. 

the  matter  by  Dr.  Labaclie-Lagrave,  in  the  appendix  to  the  French  edi- 
tion of  this  work. 

ANATOMICAL    LESIONS. 

a.  Neoplasms — Hyperplasia  of  the  Connective  Tissue. 

At  the  autopsy  of  individuals  who,  in  the  course  of  a  constitutional 
syphilis,  have  presented  brain  troubles,  the  lesions  which  are  discovered 
in  the  intra-cranial  organs  for  the  most  part  consist  of  syphilomata  or 
gummy  tumors.  As  Virchow  has  stated,  these  may  be  either  hyper- 
plastic forms  by  excess  of  normal  growths,  or  they  may  be  hetroplas- 
tic — that  is,  constituted  of  substance  not  normal  to  the  position  in 
which  it  is  found. 

The  neoplasm  is  sometimes  diffused  and  sometimes  more  or  less 
exactly  circumscribed.  According  to  my  experience,  the  latter  is 
much  the  more  common  form.  It  may  present  to  the  naked  eye  two 
different  aspects,  and  both  of  these  may  exist  in  the  same  subject. 
Thus  sometimes  the  new  growth  is  of  a  gelatiniform  consistence,  of 
a  more  or  less  grayish-red  color,  and  is  lost  imperceptibly  in  the  sur- 
rounding tissues.  Again,  it  forms  a  dense  mass  of  cartilaginous  con- 
sistence, brittle,  and  showing,  when  a  section  is  made  through  it,  a 
homogeneous  caseous  appearance.  These  yellowish-colored  masses 
are  entirely  isolated  and  completely  circumscribed.  They  are  pro- 
vided with  a  fibroid  covering. 

Sometimes  they  are  found  as  small  striated  nuclei  scattered  through 
the  reddish  gelatiniform  exudation. 

Of  these  two  varieties  of  syphilomata,  the  second  seems  to  be  de- 
rived from  the  first.  It  is  formed  of  a  basis  of  connective  tissue,  more 
or  less  altered,  in  the  meshes  of  which  are  perceived  nuclei  and  rounded 
cells.  It  is  probably  as  a  consequence  of  atrophic  degeneration  of 
their  elements  that  the  soft  and  reddish  masses  are  transformed  into 
tumors  of  a  yellowish  color  and  of  considerable  consistence.  Syphilo- 
mata of  the  nervous  centres  have  special  predilection  for  two  intra- 
cranial situations  :  the  dura  mater  and  the  sub-arachnoid  space.  Ac- 
cording to  M.  Fournier,1  cerebral  gummata  are,  in  the  great  majority 
of  cases,  peripheric — that  is,  they  are  located  in  the  cortical  layer  of 
the  hemispheres.  It  is  rarely  the  case  that  they  are  found  in  the 
central  regions,  and,  when  this  is  the  case,  it  is  almost  always  the  gray 
substance — opt  if  thalamus  and  corpus  striatum — that  they  select.  They 
are  also  much  more  commonly  found  in  the  anterior  region  of  the 
brain  than  in  the  posterior,  and  at  the  base,  especially  its  middle  por- 
tion, than  at  the  vertex. 

When  they  have  their  point  of  departure  in  the  dura  mater,  they 
are  developed  between  two  thin  laminae  of  this  membrane,  and  their 

1  "  La  syphilis  du  cerveau,"  Paris,  1879,  p.  57. 


CEREBRAL    SYPHILIS.  327 

size  varies  from  that  of  a  pigeon's  egg  to  that  of  a  hen's  egg.  The 
action  of  such  a  growth  upon  the  brain  is  that  of  simple  compression. 

When,  however,  the  neoplasm  is  developed  primarily  in  the  sub- 
arachnoid space,  it  invades  all  the  organs  (vessels,  nervous  tissue,  etc.) 
by  which  it  is  surrounded,  pressing  the  pia  mater  before  it  into  the 
substance  of  the  brain.  The  greater  number  of  syphilomata  met  with 
in  the  tissue  of  the  brain  have  this  origin.  The  neoplasm  may,  more- 
over, lose  its  circumscribed  form  and  assume  the  character  of  a  diffused 
infiltration.  It  is  very  rarely  that  it  appears  as  miliary  nodosities  sit- 
uated in  the  dura  mater  or  the  other  membranes.  Engelstedt  has  pub- 
lished a  case  of  this  kind,  as  have  also  Leon  Gros  and  Lancereaux. 

Aside  from  these  hyperplasia  it  does  not  appear  that  syphilis  has 
power  to  produce  an  encephalitis  passing  on  to  softening  or  suppura- 
tion. A  syphilitic  caries  of  a  cranial  bone  may  give  rise  to  a  suppura- 
tion which  is  propagated  to  the  dura  mater  and  cerebral  tissue,  or  a 
gumma  or  an  alteration  of  arterial  vessels,  such  as  will  presently  be 
considered,  may  be  the  point  of  departure  for  a  formation  of  pus  or  a 
simple  softening.  But,  judging  from  the  minute  analysis  of  facts  ad- 
duced by  Ileubner,1  it  has  never  been  demonstrated  that,  taking  these 
circumstances  out  of  the  question,  there  is  ever  developed  a  true  syph- 
ilitic encephalitis. 

b.  Syphilitic  Alterations  of  the  Arteries  of  the  Encephalon. 

The  alterations  which  syphilis  may  produce  in  the  arteries  of  the 
encephalon  are  numerous.  It  is  only  recently  that  they  have  attracted 
the  attention  of  pathologists,  and  are  even  yet  very  imperfectly  known. 

In  1863  Wilks  pointed  out  the  existence  of  a  gummy  arteritis, 
of  which  since  then  the  macroscopic  characteristics  have  been  well 
studied  by  different  English  authors,  especially  by  Dr.  Hughlings 
Jackson.  This  latter  observer  noticed,  as  did  also  others,  that  gummy 
arteritis  La  often  the  cause  of  thrombosis  and  softening  of  the  tissue  of 
the  encephalon. 

Quite  recently  a  German  author,  Heubner,  has  described  a  new 
variety  of  syphilitic  arteritis.  The  lesions  which  characterize  it 
-'■ited  immediately  under  the  inner  coat  of  the  artery,  between  the 
endothelium  and  the  fenestrated  membrane.  They  involve,  therefore, 
tin-  more  vascular  part  of  the  arterial  wall.  They  consist,  in  the  be- 
ginning, of  an  active  proliferation  of  the  cellular  elements  of  the  en- 
dothelium, of  which  the  products  constitute  nodosities  which  raise  the 

internal   coal  of   the  artery,  more  or   less   obliterating   the    calibre  and 

giving  rise  to  thrombosis.  The  neoplasm  sometimes  becomes  vascular 
and  forms  a  rentable  neomembrane  under  the  endothelium,  and  some- 
times undergoes  inodulary  retraction,  causing  narrowing  or  even  com- 
plete closure  of  the  vessel. 

1  "  l»i.-  luetische  Erkrankang  der  Birntrteiien,"  Lclprig,  1874. 


328  DISEASES   OF  TI1E   BRAIN. 

In  addition,  MM.  Charcot  and  Pitres  have  shown,  by  the  autopsy 
of  a  woman  who  at  the  time  of  her  death  exhibited  undeniable  syphi- 
litic cutaneous  manifestations,  the  alterations  produced  by  nodulated 
periarteritis  in  the  arteries  of  the  encephalon. 

The  several  steps  in  the  morbid  process  as  it  affects  the  cerebral 
arteries  are  far  from  being  known.  M.  Hanot,  in  a  recent  work  on 
the  subject,  has  well  put  the  questions  :  What  are  the  relations  in  evo- 
lution between  gunimata  and  the  endarteritis  of  Heubner  ?  Must  we 
admit  that  this  arteritis  is  definitely  established  ?  Are  Ave  warranted 
in  placing  periarteritis  near  it  as  another  form  of  syphilitic  arteritis  ? 
These  are  questions  which  future  researches  will  not  fail  to  elucidate. 

c.  /Syphilitic  Meningitis. 

Under  the  heads  of  "  Chronic  Verticalar  Meningitis  "  and  "  Chronic 
Basilar  Meningitis"  the  relations  of  syphilis  to  inflammation  of  the 
membranes  of  the  brain  have  been  considered  with  some  degree  of 
fulness,  and  there  is  accordingly  not  much  to  say  in  this  place. 

We  have  seen,  too,  that  the  great  majority  of  gummata  within  the 
cranium  have  their  origin  in  the  membranes,  and  particularly  in  the 
dura  mater  and  the  subarachnoid  tissue.  According  to  M.  Alfred 
Fournier,  there  can  also  be  developed  under  the  influence  of  syphilis  a 
pachymeningitis  and  a  hyperplasia  piameritis,  differing  in  no  essen- 
tial respects  from  the  ordinary  inflammations  of  the  dura  and  pia 
mater,  so  far  at  least  as  their  histology  is  concerned.  Heubner,  how- 
ever, denies  that  these  conditions  ever  exist.  According  to  the  German 
author,  there  is  no  case  on  record  in  which  the  altered  membranes  were 
submitted  to  rigid  microscopical  examination  with  the  result  of  dem- 
onstrating the  existence  of  this  simple  hyperplasia  inflammation  in  cases 
of  cerebral  syphilis.  To  the  naked  eye,  the  remains  of  a  gummy  men- 
ingitis may  present  some  signs  of  such  a  disease,  but  the  microscope 
can  alone  afford  satisfactory  evidence  of  their  real  nature. 

Sometimes  there  are  adherences  between  the  membranes  them- 
selves, and  again  adhesions  of  the  membranes  to  the  cortical  substance 
of  the  brain.  Indeed,  whenever  the  pia  mater  is  the  seat  of  syphilitic 
inflammation,  it  can  not  be  separated  from  the  cortex  without  violence 
and  resultant  tearing  away  of  the  gray  tissue. 

Syphilitic  patients  have  died  after  having  exhibited  grave  cerebral 
symptoms,  and  in  whom  after  death  no  lesions  could  be  found.  Heub- 
ner mentions  several  such  cases,  and  two  have  come  under  my  own 
observation. 

Besides  the  growths  of  the  brain  or  its  membranes,  it  must  be 
borne  in  mind  that  the  endocranium  may  be  the  seat  of  the  morbid 
formation.  In  his  excellent  work  on  cerebral  syphilis,  Dr.  Dowse  *  gives 
two  cases  of  what  were  probably  instances  of  this  kind  ;  and  most  phy- 

1  "Syphilis  of  the  Brain  aud  Spinal  Cord,"  London  and  New  York,  1879,  p.  18. 


CEREBRAL    SYPHILIS.  329 

sicians  whose  practice  throws  them  in  the  way  of  seeing  cases  of  brain 
syphilis  have  witnessed  others  similar.  Subsequently1  Dr.  Dowse  says: 
"  In  the  examinations  which  I  have  made  of  the  brain  after  death 
(over  one  thousand),  I  have  been  surprised  to  find  in  how  small  a  num- 
ber this  disease  appeared  to  originate  in  the  under  layer  of  the  peri- 
osteum of  the  endocranium.  I  think  this  may  perhaps  be  accounted 
for  by  the  fact  that  where  a  gumma  of  the  inner  table  of  the  skull  does 
arise,  the  clinical  features  as  evidenced  by  pain,  etc.,  are  so  marked  (for 
these  manifestations  usually  occur  with  the  existence  of  external  gum- 
mata)  that  remedial  measures  are  adopted  early,  and  thus  promote 
absorption  before  the  membranes  of  the  brain  become  involved." 

ETIOLOGY. 

The  cerebral  manifestations  of  syphilis  arc  very  common.  They 
may  show  themselves  at  the  beginning  of  the  secondary  period,  but 
generally  a  much  longer  time — often  many  years — after  primary  infec- 
tion elapses  before  they  appear.  Certain  circumstances  favor  the 
development  of  cerebral  syphilis.  Among  them  are  bad  specific  treat- 
ment, preexisting  nervous  affections,  emotional  disturbances,  excesses  of 
all  kinds,  and  generally  every  cause  capable  of  weakening  the  nervous 
system.  Quite  recently  I  had  a  case  under  my  charge  in  which  the 
patient,  a  gentleman  fifty  years  of  age,  was  suddenly  attacked  with 
pain  in  the  head,  vertigo,  and  paralysis  of  the  left  third  nerve,  imme- 
diately after  a  period  of  great  excitement  in  Wall  Street.  Upon  in- 
quiry I  ascertained  that  before  his  marriage,  twenty-live  years  previ- 
ously, he  had  been  treated  for  a  hard  chancre,  but  had  never  had  any 
symptoms  of  constitutional  syphilis  except  a  cutaneous  eruption  during 
the  first  year  after  infection.  Under  the  use  of  mercury  and  iodide  of 
potassium  the  brain  symptoms  entirely  disappeared  in  a  few  weeks. 

Virchow  has  expressed  the  opinion  that  the  localization  of  syphilitic 
manifestations  depends  in   many  cases  on  noxious  external  influences. 

Thus  we  sometimes  see  the  appearances  of  such  essential  phenomena 
soon  after  the  inception  of  an  injury  of  the  cranium  ;  and  it  has  long 
been  thought  thai  hydrargyrum  might  be  the  cause  of  an  inflamma- 
tion or  softening  of  the  encephalon. 

Age  is  without  special  influence  in  the  development  of  cerebral  syph- 
ilis, and  the  same  may  be  said  of  sex. 

.1  mi:  \i,   SYMPTOMATOLOGY. 

The  variety  in  Che  situation  and  in  the  nature  of  syphilitic  lesions 
of  the  encephalon  causes  great  differences  in  their  symptomatology. 

A  prodromatic  Blgn  of  much  value  on  account  of  its  constancy  is  head- 
ache.    This  Bymptom  is  always  worthy  of  great  attention,  for  it  often 

1  Op.  cit,  p.  104. 


330  DISEASES   OF   THE   BRAIN. 

precedes  for  a  long  time  the  appearance  of  more  grave  manifestations; 
for  it  is  of  great  importance  to  prevent  the  development  of  conditions 
which  it  may  be  difficult  to  remove.  "  It  is  everything,"  says  M.  Four- 
nier,  "  to  recognize  cerebral  syphilis  in  its  beginning  and  to  discover  its 
origin." 

According  to  this  judicious  observer,  headache,  when  prodromatic 
of  cerebral  syphilis,  presents  itself  under  the  three  following  types  : 

1.  Severe  pain,  with  a  sensation  of  weight. 

2.  Constrictive  pain,  seeming  to  the  patient  as  though  the  head 
were  about  to  split  open. 

3.  Pains  as  if  from  blows  with  a  hammer,  instantaneous  and  ex- 
tremely severe. 

These  several  forms  of  headache  may  be  met  with  in  the  same 
patient.  Generally  they  are  particularly  manifested  during  the  night, 
as  is  the  case  with  osteoscopic  pains.  Without  medical  treatment, 
they  may  disappear  after  a  few  months  to  return  again  spontaneously. 
It  is  rarely  the  case  that  the  pain  occupies  the  whole  head,  being  either 
unilateral  or  limited  to  the  anterior  or  posterior  region.  It  may  even 
occupy  a  very  circumscribed  spot,  and  then  presents  all  the  character- 
istics of  the  clavus  hystericus.  According  to  M.  A.  Fournier,  "  a 
violent  and  intense  pain  in  the  head,  with  nocturnal  exacerbations  of 
long  duration,  chronic,  and  frequently  recurring,  is  a  symptom  that 
almost  invariably  indicates  the  existence  of  syphilis,  and  which  should 
always  excite  suspicion." 

It  is  proper  to  insist  upon  the  following  point  :  Headache  is  re- 
garded generally  as  an  essentially  prodromatic  symptom  in  the  sense 
that  it  has  for  its  cause  in  many  cases  lesions  of  the  walls  of  the  cra- 
nium, and  appears  first  at  a  time  when  the  intracranial  organs  have 
not  yet  suffered  morbid  change  (Hueter).  Later,  when  the  dura  mater 
is  involved,  the  headache  becomes  more  obstinate,  more  fixed,  and  is 
then  no  longer  a  prodromatic  symptom.     It  is  cerebral  syphilis  itself. 

Among  the  other  symptoms,  insomnia  must  be  placed  in  the  front 
rank.  It  may  depend  directly  upon  the  cephalalgia,  but  is  often  ob- 
served when  there  is  no  pain  in  the  head.  This  symptom  especially 
demands  attention  when  it  is  met  with  in  young  subjects. 

Among  the  other  phenomena  are  vertigo  and  sensations  of  faint- 
ness,  a  feeling  of  weight  in  the  head,  failure  of  memory,  difficulty  in 
concentrating  the  attention  and  forming  ideas,  and  even  aberration  of 
the  faculty  of  speech,  either  as  a  forgetfulness  of  words  or  an  embar- 
rassment in  pronouncing  them  properly.  Sometimes  there  are  great 
intellectual  and  moral  depression,  and,  again,  there  is  undue  mental 
exaltation.  These  conditions  may  be  combined  in  the  same  individual, 
alternating  with  each  other  ;  often  they  are  so  slight  as  not  to  attract 
the  attention  of  the  patient,  who  does  not  consult  a  physician  till  some 
more   grave   symptom,  such  as  an  epileptiform  seizure,   alarms  him. 


CEREBRAL    SYPHILIS.  331 

Such  attacks  may  supervene,  while  there  is  every  appearance  of  excel- 
lent health,  and  may  recur  at  distant  intervals.  In  general,  the  later 
they  are  in  appearing,  the  more  persistent  they  are  in  remaining. 
Sometimes  the  paroxysm,  is  not  to  be  distinguished  from  one  of  true 
epilepsy  ;  at  other  times  it  lacks  the  initial  cry  or  the  convulsive  move- 
ments, or  is  limited  to  one  side  of  the  head,  as  in  symptomatic  epilepsy. 
Quite  often  the  convulsive  crisis  is  followed  immediately  by  the  phe- 
nomena of  motor  paralysis.  A  syphilitic  epilepsy  may  only  be  mani- 
fested under  the  form  of  the  petit  mal. 

M.  Alfred  Fournier  has  insisted,  in  his  lectures  on  this  subject, 
that  in  many  cases  of  syphilitic  epilepsy  there  are  no  pathognomonic 
characteristics  distinguishing  the  attack  from  one  of  common  epilepsy 
— that  it  is  an  error  to  assert,  as  have  some  authorities,  that  in  syphi- 
litic epilepsy  the  paroxysms  are  particularly  apt  to  occur  in  the  night, 
and  that  they  follow  each  other  with  great  rapidity  for  a  while,  and 
then  cease  for  a  long  period.  The  only  symptoms,  according  to  him, 
are  the  following  : 

The  convulsive  phenomena  are  complicated  with  other  cerebral 
manifestations,  such  as  paralysis  of  a  cranial  nerve  or  optic  neuritis, 
which  persists  during  the  intervals  between  the  attacks. 

The  convulsions,  instead  of  .beginning  in  early  life,  do  not  appear 
till  after  puberty,  and  then  subsequently  to  a  constitutional  syphilis, 
which  has  arrived  at  its  secondary  period. 

It  is  certainly  true,  as  Mauriac '  declares,  that  epilepsy  is  not  gener- 
ally among  the  earlier  manifestations  of  cerebral  syphilis.  Neverthe- 
less, I  have  seen  several  cases  in  which  an  epileptic  paroxysm  was 
the  very  first  evidence  that  the  brain  was  involved.  Mental  troubles 
sometimes  then  appear  as  depressing  feelings,  consisting  of  a  kind  of 
intellectual  torpor,  which  advances  slowly,  in  which  there  is  notable 
weakening  of  the  memory,  and  which  finally  terminates  in  melancho- 
lia or  mania.  At  other  times  the  psychical  phenomena  pursue  a  rapid 
course,  and  consist  of  periods  of  great  excitement,  variability  of 
character  and  disposition,  hallucinations,  and  furious  delirium.  These 
troubles  of  the  intelligence  may  degenerate  into  complete  dementia. 
Bell  has  reported  i  case  of  insanity  which  existed  in  a  syphilitic  patient. 

which  lasted  two  years,  and  was   then  cured  by  a  mercurial  treatment. 

b  sometimes  happens  that  cerebral  syphilis  is  manifested  under 
the  form  of  general  paralysis  of  the  insane,  though  sometim< 
Wilks  has  asserted,  the  delm  des grandeurs  is  absent.  Fournier  is  of 
the  opinion  thai  while  general  paralysis  may  he  developed  in  a  syphi- 
litic lesion,  it  has  not  been  demonstrated  th.it  syphilis  exercises  any 
influence  in  the  production  of  this  disease.  According  to  the  eminenl 
physician  of  the  Saint    bonis  Bospital,  of   Paris,  the  affection  which 

1  "  Mrmuiiv  but  lei  affections  syphilitiqucf  |  ■  -  centres  nerveux,"  Paris,  is;o, 

p.  1  c.J. 


332  DISEASES   OF   TEE   BRAIN. 

some  have  taken  for  general  paralysis  of  the  insane  is  only  a  common 
general  paralysis,  which  admits  of  cure  hy  proper  anti-syphilitic  treat- 
ment. However  all  this  may  be,  it  is  certainly  true  that  general 
paralysis  of  the  insane  is  not  infrequently  developed  in  the  course  of 
constitutional  syphilis,  and  that  there  is  just  as  much  reason  for  re- 
garding it  as  of  syphilitic  origin  as  epilepsy,  or  other  manifestations 
of  the  disease,  as  it  affects  the  brain 

Aphasia. — Troubles  of  speech  are  very -frequent  in  the  course  of 
cerebral  syphilis.  They  present  themselves  under  variable  aspects,  some- 
times being  of  early  appearance  and  again  not  coming  till  late.  They 
may  consist  of  only  a  slowness  of  speech,  the  articulation  being  explo- 
sive or  staccato,  as  is  the  case  in  paralysis  agitans ;  at  other  times  there  is 
motor  aphasia.  This  is  shown  by  a  difficulty  in  pronouncing  words  or 
of  associating  them  in  a  sentence.  Again,  there  may  be  word-deaf- 
ness, word-blindness,  agraphia,  or  amnesia,  these  symptoms  coinciding 
with  the  occurrence  of  lesions  in  the  cortex,  or  just  beneath  it,  in  re- 
gions which  have  already  been  fully  described  in  a  previous  chapter  on 
aphasia.  The  lesions  usually  found  consist  of  gummata,  meningeal  in- 
duration, and  syphilitic  arteritis  with  softening.  It  often  happens  that 
the  aphasia  disappears  with  as  much  suddenness  as  it  is  developed,  in 
which  case  it  is  probably  due  to  congestion  in  the  course  of  the  speech 
tract.  Not  long  since  I  reported1  an  interesting  case  of  this  kind  ;  an- 
other is  detailed  in  the  present  treatise  (page  232)  ;  several  have  been 
given  by  Tarnowsky,2  and  Fournier3  declares  that  when  it  occurs  as  an 
early  manifestation  of  cerebral  syphilis  it  is  almost  always  ephemeral. 

Motor  Paralysis. — The  cortical  lesions  which  give  rise  to  aphasia 
frequently  involve  the  neighboring  motor  zone.  It  is  therefore  not 
surprising  to  find  syphilitic  aphasia  complicated  with  a  more  or  less 
complete  motor  paralysis  of  the  right  side.  But  the  paralysis  due  to 
syphilis  of  the  brain  may  of  course  appear  on  either  side  of  the  body. 

It  is  rarely  complete  in  the  beginning.  It  advances  slowly,  with 
periods  of  amendment  and  of  aggravation,  and  is  complicated  with 
convulsive  seizures.  It  has,  in  fact,  all  the  characteristics  of  cortical 
paralyses.  It  must  be  borne  in  mind  that  syphilitic  lesions  of  the  en- 
cephalon  are  most  commonly  met  with  in  the  membranes  and  in  the 
cortical  substance  of  the  hemispheres  (twelve  out  of  fourteen,  accord- 
ing to  Jaksch).  The  paralysis  of  the  limbs  is  often  preceded  by  that 
of  a  cranial  nerve.  Thus,  for  example,  a  patient  who  is  apparently  in 
perfect  health  suddenly  becomes  the  subject  of  ptosis,  strabismus  or  di- 
plopia, and  at  other  times  of  a  diminution  of  visual  power.  Again, 
the  muscles  of  the  face  are  the  seat  of  temporary  contractions,  or  a 

1  "Syphilitic  Aphasia;  Neurological  Contributions,"  No.  1,  vol.  i.,  New  York,  1879, 
p.  62. 

2  "  Aphasie  syphilitique,"  Paris,  1870. 
8  Op.  ell.,  p.  242. 


CEREBRAL   SYPHILIS.  333 

neuralgia  of  the  fifth  pair  is  developed.  These  phenomena,  which 
may  disappear  and  reappear  many  times,  generally  precede  by  several 
months,  or  even  years,  paralysis  of  the  limbs. 

It  is  rarely  the  case  that  paralysis  of  syphilitic  origin  begins  with 
an  apoplectiform  seizure.  When  this  does  occur,  the  apoplectic  attack 
is  generally  the  immediate  result  of  some  strong  emotional  disturbance 
or  an  alcoholic  or  venereal  excess.  In  such  cases  the  resemblance  to 
hemiplegia  from  cerebral  haemorrhage  or  embolism  is  complete;  but 
when  it  is  complicated  with  decided  syphilitic  manifestations  its  spe- 
cific origin  is  extremely  probable.  M.  Founder  asserts  that  seventy- 
five  out  of  every  one  hundred  cases  of  ocular  paralysis  are  syphilitic; 
but  it  is  probable  that  the  proportion  is  not  nearly  so  great  as  this, 
and,  with  M.  Charcot,  we  must  recognize  the  fact  that  many  cases  of 
such  paralysis  are  the  initial  phenomena  of  locomotor  ataxia. 

Troubles  of  vision  are  very  frequent  in  the  initial  period  of  syphi- 
lis. According  to  M.  Founder,  both  eyes  are  generally  affected,  and 
the  morbid  process  advances  very  rapidly.  All  degrees  of  weakness 
of  vision,  from  a  slight  amblyopia  to  complete  blindness,  are  observed. 
I  have  a  case  now  in  mind,  which  I  saw  in  New  Jersey  a  year  ago,  in 
which  the  blindness  was  so  intense  that  the  passage  of  a  bright  light 
before  the  eyea  was  not  noticed,  and  yet  in  less  than  two  months, 
under  the  use  of  large  and  increasing  doses  of  iodide  of  potassium  and 
the  moderate  use  of  mercury,  the  sight  was  entirely  restored.  Gener- 
ally these  visual  troubles  are  complicated  with  other  phenomena,  such 
as  headache,  convulsive  seizures,  etc.  They  depend  upon  optic  neuri- 
tis, which  offers  to  the  ophthalmoscope  no  essential  differences  from 
the  non-specific  form  of  the  affection. 

Derangements  of  the  sense  of  hearing  are  also  common  among 
the  early  symptoms  of  cerebral  syphilis.  They  are  probably  due  to 
inflammation  or  congestion  of  the  auditory  nerves,  and  usually  are 
met  with  in  both  cases,  lake  the  \  isual  troubles  from  like  cause,  they 
are,  if  not  of  too  long  duration,  amenable  to  treatment,  and  sometimes 
disappear  with  great  suddenness. 

The  duration  of  cerebral  syphilis  depends  upon  the  nature  of  the 
encephalic  lesions  and  upon  the  treatment  directed  against  it.  Affec- 
tions of  the  arteries  are  the  gravest  in  character,  since  they  may  re- 
sult in  an  apoplectic  attack  due  to  a  thrombosis  of  our  or  more  of  the 
vessels.  Under  such  a  circumstance  the  patient  dies  ina  few 
d  ijt  in  a  Bt  ile  of  complete  coma.  Whatever  may  be  the  lesion,  death 
may  occur,  and  in  fad  doe.  often  supervene.      (  )n  the  contrary,  a  cure 

may  !"■  almost  certainly  obtained,  more  or  less  complete  in  character. 

when  the  proper  treatment   is   initiated  early  and    carried    OUt   with  elli- 

cienoy. 


334  DISEASES   OF   THE   BRAIN. 

CHAPTER  XVII. 

SYMPTOMATOLOGY  OF  CEREBRAL  LESIONS. 

I. 

CORTICAL     PARALYSES. 

For  a  long  time  it  was  believed  that  the  different  regions  of  the 
cortical  substance  of  the  brain  were  endowed  with  the  same  functions, 
and  that  thought,  memory,  volition,  and  perception  had  a  common  re- 
lation to  all  parts  of  the  gray  substance  forming  the  external  surface 
of  the  convolutions.  Flourens,  studying  the  effects  of  partial  disturb- 
ance of  this  gray  substance,  arrived  at  the  conclusion  that  the  results 
were  the  same  whatever  was  the  seat  of  the  lesion. 

In  1S64,  as  has  already  been  brought  to  the  notice  of  the  reader, 
the  researches  of  Broca  demonstrated  the  existence  of  a  special  centre 
for  language — a  fact  which  Bouilland  and  Dax  had  previously  done 
much  to  establish.  This  centre  was  shown  to  be  situated  either  in  the 
posterior  part  of  the  left  third  frontal  convolution,  or  in  the  corre- 
sponding part  of  the  right  third  frontal  convolution,  according  as  the 
individual  was  right-  or  left-handed.  For  a  long  time  no  further  prog- 
ress was  made  in  the  direction  of  localization,  and  no  one  ventured 
to  extend  the  discovery  of  Broca  and  to  apply  its  principles  to  other 
functions,  the  seat  of  which,  all  agreed,  was  in  the  gray  substance  of  the 
hemispheres. 

In  1870,  the  German  physiologist  Hitzig,  applying  a  galvanic  cur- 
rent to  the  gray  substance  of  the  hemispheres — until  then  regarded  as 
inexcitable — saw,  to  his  great  astonishment,  muscular  contractions  pro- 
duced in  the  opposite  side  of  the  body.  Moreover,  the  galvanic  excita- 
tion of  the  same  part  on  the  surface  of  the  hemispheres  always  produced 
contractions  in  the  same  group  of  muscles.  Such,  in  fact,  were  the  rela- 
tions between  the  irritated  region  of  the  cerebral  cortex  and  the  groups 
of  muscles  which  contracted  under  the  influence  of  the  excitation,  that 
Ferrier,  repeating  on  a  monkey  the  experiments  of  Hitzig,  before  the 
Royal  College  of  Physicians  of  London,  has  been  able  to  predict  what 
group  of  muscles  lie  would  cause  to  contract. 

These  experimental  results  of  Hitzig  and  Ferrier  have  caused  a  com- 
plete revolution  in  our  views  relative  to  the  physiology  of  the  brain, 
for  they  have  shown  that  the  gray  substance  forming  the  periphery  of 
the  hemispheres  is  not,  as  had  been  thought,  inexcitable.  And,  on  the 
other  hand,  the  question  of  cerebral  localization  has  received  a  degree 
of  elucidation  which  has  already  led  to  avast  amplification  of  ourknowl- 
edge  of  cerebral  physiology  and  pathology.  It  is  therefore  scarcely 
a  matter  of  doubt  that  the  several  groups  of  muscles  of  the  body  are 
it:  direct  anatomical  and  physiological  relation  with  as  many  ideomotor 


SYMPTOMATOLOGY   OF   CEREBRAL   LESIONS.  335 

centres,  occupying  each  its  distinct  position  in  the  anterior  regions  of 
the  gray  matter  of  the  convolutions.  After  performing  a  great  many 
experiments,  Hitzig  arrived  at  the  conclusion  that  the  exact  situation 
of  each  one  of  these  centres  was  a  matter  of  certainty.  He  assigned 
to  them  the  ascending  frontal  convolution  as  common  property.  The 
superior  part'  of  this  convolution  contains  the  centres  of  movements 
for  the  lower  extremity  of  the  opposite  side  of  the  body.  Passing 
downward,  we  come  successively  to  the  centre  for  the  upper  extremity, 
that  for  the  face,  and  the  centre  for  the  movements  of  the  lips  and  the 
tongue. 

But  facts  deduced  from  experiments  contradictory  of  the  results 
obtained  by  Hitzig  were  not  slow  in  being  brought  forward.  Sampt, 
supported  by  a  ease  in  which  a  cysticucus  was  situated  in  the  ascending 
frontal  convolution  without  giving  rise  to  any  troubles  of  motility 
of  the  opposite  side,  denied  all  connection  between  the  functions  of 
this  convolution  and  voluntary  motion.  According  to  Goltz,  the  ef- 
fects consecutive  to  the  destruction  of  a  limited  portion  of  the  gray 
substance  of  the  convolutions  are  not  dependent  on  the  seat,  but  only  on 
the  extent  of  the  lesion.  These  effects  would  be  the  same  whether  the 
experiment  were  performed  on  the  anterior  or  posterior  part  of  the 
bemispher<  3,  always,  however,  affecting  not  only  motion,  but  general 
Bensibility  and  vision  as  well.  These  results  of  Goltz,  however,  lose 
much  of  their  value  from  the  fact  that  the  author,  as  he  himself  de- 
clares, practiced  very  considerable  mutilations  of  the  animals  subjected 
to  experiment.  On  the  contrary,  Ferrier,  substituting  galvanic  or  fara- 
daic  electricity  as  the  exciting  agent,  found  that  there  was  undoubt- 
edly a  motor  zone  in  the  anterior  part  of  the  gray  Bubstance  of  the 
hemispheres,  lie,  however,  limited  the  extent  of  this  zone  to  about 
the  anterior  two  thirds  of  the  surface  of  the  brain  ;  that  is  to  say,  to  a 
Bpace  ten  times  larger  than  the  space  occupied  by  the  ascending  frontal 
convolution.  [Terrier's  results  have  been  confirmed  by  MM.  Carville 
and  Duret,  who  have  had  recourse  to  an  inverse  process,  they  haying 
studied  nol  only  the  influence  produced  by  excitation,  bul  also  that 
caused  by  partial  destruction  of  the  cortical  Bubstance. 

The  researches  of  Betz  have  given  an  anatomical  hasis  to  the  theory 
of  cerebral  localizations.  This  observer,  having  submitted  minute  por- 
tions of  the  cortical  Bubstance  of  the  hemispheres  to  microscopical  ex- 
amination, discovered  two  regions  which  were  distinguished  from  the 
resl  of  the  convolutions  by  the  presence  of  large  pyramidal  cells  meas- 
uring <»''.!-  in  their  long  and  0"  ".06  in  their  short  diameter.  Tin1  firsl 
of  these  regions  embraced  the  anterior  central  convolution  and  the 

superior  pari  of  the  posterior  central  convolution  as  well  as  the  para- 
central lobe.  The  second  occupied  a  variable  extent  with  different  in- 
dividuals, reaching  as  far  as  the  point  of  the  occipital  lobe.  These 
larger  ganglionic  cells  are  particularly  abundant  about  the  right  para- 


336  DISEASES   OF   THE   BRAIN. 

central  lobe.  Betz  is  of  the  opinion  that  of  these  two  regions  the  ante- 
rior corresponds  to  the  motor  zone,  while  the  posterior  is  probably  the 
centre  for  the  perception  of  sensitive  impressions.  The  gray  substance 
of  the  convolutions  appears,  therefore,  to  be  arranged  and  have  func- 
tions corresponding  to  those  of  the  gray  matter  of  the  spinal  cord. 

If  distinct  motor  centres,  each  having  dependent  upon  it  a  certain 
group  of  muscles,  really  exists  in  the  anterior  part  of  the  surface  of  the 
hemisphere,  lesions  destructive  of  the  region  of  the  cortex  represent- 
ing one  of  these  centres  ought  to  produce  paralysis  of  the  muscles  in 
relation  therewith. 

This  point  has  lately  occupied  the  attention  of  pathologists,  and  it 
has  been  ascertained  that  the  evidence  supplied  by  pathological  anat- 
omy and  clinical  observation  points  still  more  strongly  than  the  results 
of  experiment  to  the  exactness  of  Hitzig's  conclusions. 

Thus  MM.  Charcot  and  Pitres  have  collected  in  a  remarkable  work 
a  certain  number  of  cases  going  to  show  the  relations  existing  between 
paralyses  and  distinctive  lesions  of  the  gray  substance  of  the  convolu- 
tions. In  all  these  cases  the  seat  of  the  cortical  lesion  was  indicated 
with  the  utmost  exactness.  Hence  they  arrive  at  the  conclusion  that 
the  cortex  of  the  brain  contains  a  motor  zone,  and  that  this  motor  zone 
occupies  the  paracentral  lobe,  the  two  ascending  convolutions,  and 
probably  also  the  inferior  portion  of  the  three  frontal  convolutions.  In 
the  cases  cited  by  MM.  Charcot  and  Pitres,  all  cortical  lesions,  what- 
ever their  extent  outside  of  this  motor  zone,  were  powerless  to  cause 
troubles  of  motility.  On  the  other  hand,  destructive  lesions,  even 
when  of  very  limited  extent,  situated  within  this  zone,  constantly  pro- 
duced motor  disturbance.  The  paralysis  wras  of  sudden  origin  Mrhen 
the  lesion  had  been  suddenly  produced,  and  it  was  limited  to  a  part 
only  of  one  side  of  the  body  when  the  lesion  wTas  restricted  to  a  part 
only  of  the  motor  zone.  MM.  Charcot  and  Pitres,  moreover,  think 
they  are  warranted  in  concluding,  from  their  study  of  paralyses  and 
convulsions  of  cortical  origin,  that  the  motor  centres  for  the  upper  and 
lower  extremities  are  seated  in  the  paracentral  lobe  of  the  opposite 
side  and  in  the  two  upper  thirds  of  the  ascending  convolutions,  and  that 
the  centres  for  the  movements  of  the  lower  part  of  the  face  are  placed 
in  the  inferior  third  of  the  ascending  convolutions  in  the  vicinity  of 
the  fissure  of  Sylvius,  and  finally  that  it  is  very  probable  that  the  centre 
for  isolated  movements  of  the  upper  extremity  is  situated  in  the  mid- 
dle third  of  the  ascending  frontal  convolution  of  the  opposite  side. 

Quite  recently  MM.  Charcot  and  Pitres  have  published  a  new  mem- 
oir, in  which  they  have  collected  a  number  of  cases  of  cortical  lesions 
situated  exteriorly  to  the  motor  zone,  and  which  have  not  produced 
any  derangement  of  motion.  From  these  facts,  collected  from  different 
authors,  these  observers  have  drawn  the  following  conclusions,  which, 
it  will  be  perceived,  are  in  accordance  with  their  own  results  :  "There 


SYMPTOMATOLOGY   OF   CEREBRAL   LESIONS. 


337 


Side  view  of  the  brain  of  man  and  the  areas  of  the  cerebral  convolutions. 
(After  Furrier.) 

1  (On  the  postero-parietal  [superior  parietal]  lobule),  advance  of  the  opposite  hind-limb  as 
in  walking.  2,  3,  4  (Around  the  upper  extremity  of  the  tissure  of  Rolando),  complex 
movements  of  the  opposite  leg  and  arm,  and  of  the  trunk,  as  in  swimming  :  <*, &,  <',  d  (on 
the  postero-parietal  [posterior  central]  convolution  |,  individual  and  combined  movements 
of  tin;  fingers  and  wrist  of  the  opposite  hand:  prehensile  movements.  5  (At  the  pos- 
terior extremity  of  the  superior  frontal  convolution),  extension  forward  of  tl:>-  op] 
arm  and  hand.  6  (On  the  upper  part  of  the  antero-parietal  or  ascending  frontal  [ante- 
rior oentral  convolution),  supination  and  flexion  of  the  opposite  fore-arm.  V  (On  the 
median  p  irtion  of  the  same  convolution),  retraction  and  elevation  of  the  opposite  anslo 
of  the  mouth  by  means  of  the  zygomatic  muscles  :  8  (Lower  down  on  the  same  convolu- 
tion), elevation  of  the  ala  nasi  and  upper  lip  with  depression  of  the  lower  lip,  on  tho 
opposite  side.  0,  10  At  the  inferior  extremity  of  the  same  convolution,  Broca'e  con- 
volution), opening  of  the  mouth  with  9,  protrusion,  and  10,  retraction  of  the  tongue — 
region  of  aphasia,  bilateral  action,  il  (Between  10  and  the  inferior  extremity  of  the 
postero-parietal  convolution),  retraction  of  the  opposite  angle  of  the  mouth,  the  head 
turned  slightly  to  one  side.  19  (On  the  posterior  portions  of  the  superior  and  middle 
frontal]  convolutions),  the  eyes  open  widely,  the  pupils  dilate,  and  the  head  and 
turn  toward  the  opposite  side.  18,  13  (On  the  supra-marginal  lobule  and  angular 
gyrus),  the  eyes  move  toward  the  opposite  side  with  an  upward  18,  or  downward  18, 
deviation;    the  pupils  generally  contracted  f  vision).     U  (Of  the  infra-mar- 

ginal, or  superior  [flrsi  |  t.  mporo  sphenoidal  convolution),  pricking  of  •  ■  ear, 

the  head  and  eyes  tura  to  the  opposite  side,  and  the  pupils  dilate  largelj   (oentreof 
hearing),     Ferrier,  moreover,  places  the  centres  of  taste  and  smell  at  the  extremity  of 
the  temporo-sphenoida]  lobe,  and  that  of  touch  in  the  gyrus  undnatus  and  hippocam- 
pus major,    i  After  Ranney.) 
23 


338  DISEASES   OF   THE   BRAIN. 

exist  in  the  cortex  of  the  cerebral  hemispheres,  regions  which  have  no 
relation  with  the  power  of  motion,  and  in  which,  consequently,  lesions 
may  be  produced  without  permanent  trouble  of  the  motor  functions. 
These  regions  comprise  the  occipital  lobe,  the  sphenoidal  lobe,  the  an- 
terior part  of  the  frontal  lobe,  the  orbital  lobe,  the  parietal  lobes  (except 
perhaps  their  feet),  the  quadrilateral  lobe,  and  the  cuneiform  lobe." 

Experimental  physiology  and  clinical  observation  agree  that  there 
exists  on  the  periphery  of  the  hemisphere  a  motor  zone,  embracing  the 
pre-central  gyrus,  the  post-central  gyrus,  and  the  posterior  extremities 
of  the  three  frontal  gyri.  At  the  same  time  it  may  be  considered  an 
established  fact  that  electrical  or  pathological  excitation  of  this  zone 
engenders  contractions  of  the  muscles  of  the  opposite  side  of  the  body, 
while  destructive  lesions  involving  this  zone  produce  motor  paralysis 
of  the  same  muscles.  But  we  can  even  go  further  than  this,  for  in 
the  present  state  of  our  knowledge  it  is  quite  possible  for  us  to  deduce 
from  the  seat  of  the  paralysis  the  exact  situation  of  the  cortical  lesion. 
It  is  more  than  probable  that  the  motor  zone,  the  existence  of  which  is 
not  a  matter  of  doubt,  is  divided  into  a  certain  number  of  regions,  each 
one  having  its  distinct  function.  In  other  words,  it  can  be  freely  con- 
ceded that  a  given  group  of  muscles  is  under  the  exclusive  control  of 
a  single  ideo motor  centre  located  in  a  determinate  part  of  the  motor 
zone.  The  different  motor  cells  of  this  zone  are  in  intimate  relation 
with  each  other,  and  they  communicate,  on  the  other  hand,  with  motor 
fibres  which  go  to  the  contractile  organs  of  the  periphery.  It  is  ap- 
parent, therefore,  that  when  a  portion  of  the  motor  centre  is  destroyed 
by  a  pathological  alteration,  the  muscles  which  are  paralyzed  are  those 
which  are  in  anatomical  connection  with  the  cells  situated  in  the  dis- 
ordered part  of  the  cortex.  Now  we  have  a  very  definite  knowledge 
relative  to  the  course  of  the  motor  fibres  in  the  centrum  ovale,  and  of 
their  distribution  to  the  periphery  of  the  cortex.  There  is  every  proof 
that  the  fibres  destined  to  a  particular  group  of  muscles  come  from 
neighboring  cells  of  the  motor  zone.  We  must,  therefore,  conclude 
that  there  are  various  cortical  centres,  each  one  of  which  is  connected 
directly  with  a  particular  set  of  muscles.  Ferrier  holds  that  these 
centres  are  limited  by  sharply  demarked  lines,  but  I  think  the  evidence 
goes  to  show  that  Horsley's  view — "  that  in  one  spot  especially  the  rep- 
resentation is  concentrated  and  thence  diminishes  gradually  " — is  the 
more  correct. 

II. 

PARALYSES    CONSECUTIVE    TO    CENTRAL   LESIONS    OF   THE    HEMISPHERES. 

The  cerebral  hemispheres,  attached  on  each  side  to  a  corresponding 
peduncle,  are  composed  of  certain  nuclei  of  gray  matter  (central  gan- 
glia), among  which  pass  lamina?  of  white  tissue,  which  constitute  the 


SYMPTOMATOLOGY   OF   CEREBRAL   LESIONS. 


339 


Fig.  26. 


greater  part  of  the  substance  of  which  each  lateral  half  of  the  brain  is 
constructed.  These  gray  nuclei  are  three  on  each  side — the  lenticular 
nucleus,  the  caudated  nucleus,  and  the  optic  thalamus.  The  first  two 
are  sometimes  designated  the  extra-ventricular  and  intra-ventricular 
nuclei  respectively,  and  together  constitute  the  corpus  striatum.  The 
caudated  nucleus  and  the  optic  thalamus  are  separated  from  the 
lenticular  muscles  by  a  lamina  of  white 
substance  called  the  internal  capsule, 
which  by  its  expansion  constitutes  the 
corona  radiata.  These  relations  are 
clearly  shown  in  the  accompanying 
diagram  (Fig.  2G)  of  a  horizontal  sec- 
tion of  the  brain. 

The  internal  capsule  may,  for  con- 
venience, be  divided  into  anterior  and 
posterior  halves,  the  line  of  demarka- 
tion  being  at  the  "  knee "  or  bend. 
With  the  function  of  the  anterior  half 
we  are  as  yet  unacquainted,  but  with 
the  posterior  half  our  knowledge  is 
more  definite.  The  posterior  third  of 
the  jjosterior  half  is  composed  exclu- 
sively of  sensory  fibres,  which  wind 
around  the  posterior  extremity  of  the 
lenticular  nucleus  and  terminate  in  the 
cortex.  Ferrier  and  ITorsley  both  con- 
sider that  the  gyrus  fornicatus  and  the 
gyrus  hippocampus  contain  the  cortical 
centres  for  the  cutaneous  sensations. 
But  other  evidence,  principally  con- 
tribute 1  by  Munck,  Kxner,  Luciani,  and 
Sepilli,  and  ably  condensed  and  aug- 
mented by  Dana,1  demonstrate  almost 
conclusively  that  the  termination  of  the  sensory  tract  for  the  expres- 
sion of  touch,  pain,  and  temperature  in  the  cortex  is  in  the  precen- 
fcral  and  post-central  gyri,  and  perhaps  even  a  little  posteriorly.  This 
tract  can  l»e  traced  downward  through  the  formatio  reticularis  in  the 

medulla  to  the  sensory  tract  in  the  spinal  cord.  The  muscular  sense  is 
transmitted  by  fibres  Which  apparently  originate  in  the  nucleus  gracilis 
and  QUCleUS  CUneatUS  in  the  medulla.  These  nuclei  are  the  termina- 
tions of    Burdach's  and  Goll's  Columns   in  the  spinal    cord.      This   tract 

decussates  in  the  medulla,  and,  passing  up  through  the  inter-olivary 

tract,  joins  the   sensory  trad   in  the  internal  oapsule  and  terminate-    in 

centres  situated  in  the  parietal  cortex. 

1  "Cortical  Localization*  of  the  Cutaneous  Sensations,"  Journ,  Nerv.  and  SfmU,  l>  ■  , 
Oct,  1888. 


Horizontal  section  through  the  brain, 
showing  the  internal  capsule  with 
its  motor  and  sensory  divisions. 
T,  tongue  fibres.  /•',  race  fibres. 
./,  arm  fibres.      TV,  trunk 

Z,  leg  fibres. 


340  DISEASES  OF  TIIE  BRAIN. 

The  anterior  two  thirds  of  the  posterior  half  of  the  internal  capsule 
consists  entirely  of  motor  fibres.  This  tract  terminates,  on  the  one 
hand,  in  the  cells  of  the  motor  centres  of  the  cortex  (Fig.  25),  and  on 
the  other  hand,  after  partly  decussating  in  the  pons,  is  continued  in 
the  lateral  and  anterior  pyramidal  tracts  in  the  spinal  cord. 

These  statements  of  the  anatomy  of  the  parts  concerned  are 
necessary  for  the  full  comprehension  of  the  morbid  conditions  induced 
by  lesions  of  the  different  regions  of  the  central  mass  of  the  hemi- 
spheres. 

a.  Lesions  of  the  Posterior  Third  of  the  Internal  Capsule. 

Cerebral  Haimi-anwsthesia. — When  a  lesion  involves  the  posterior 
third  of  the  posterior  half  of  the  internal  capsule,  that  portion  com- 
prised between  the  optic  thalamus  and  the  posterior  part  of  the  len- 
ticular nucleus,  it  is  manifested  by  total  ha3rni-ana?sthesia,  both  as  re- 
gards the  skin  and  the  other  organs  of  special  sense,  and  is  situated  on 
the  side  opposite  to  that  of  the  lesion.  This  is  demonstrated  by  facts 
furnished  by  Andral,  Ttirck,  Rosenthal,  Jackson,  Charcot,  Vulpian, 
Luys,  Rendu,  Veyssiere,  and  others.  This  general  haemi-ansesthesia 
is  explained  when  we  call  to  mind  the  fact  that  the  lenticulo-optic 
portion  of  the  internal  capsule  contains  all  the  sensorial  fibres  which 
come  from  the  opposite  side  of  the  body.  Experimental  physiology 
confirms  the  data  which  are  supplied  by  clinical  experience  and  anat- 
omy. The  researches  of  Vulpian,  and  of  Duret  and  Veyssiere,  his 
pupils,  demonstrated  that  experimental  lesions  of  the  posterior  third 
of  the  internal  capsule  produce  complete  hsemi-ansesthesia  of  the 
opposite  side  of  the  body. 

From  a  clinical  stand-point  bamii-ana^sthesia  of  cerebral  origin 
does  not  in  any  respect  differ  from  the  like  condition  induced  by 
hysteria.  In  both  cases  general  sensibility  is  abolished  in  one-half  of 
the  body,  in  all  its  different  expressions,  while  at  the  same  time  the 
other  special  senses  are  abolished  or  deranged  on  the  same  side.  As 
regards  the  sight  in  hysteria,  there  is  not  only  a  diminution  of  the 
power  of  vision  which  may  be  in  one  eye  only,  but  there  is  a  concen- 
tric and  general  narrowing  of  the  visual  field,  with  central  scotomata, 
which  are  generally  transient,  while  the  color  field  is  narrowed  or 
else  is  entirely  lost. 

In  unilateral  lesions  of  the  hemispheres  the  theory  of  A.  von  Graefe, 
that  the  usual  trouble  observed  is  a  simple  abolition  of  sight  in  the 
corresponding  field  of  vision  of  both  eyes — in  other  words,  a  homony- 
mous lateral  hemianopsia — is  generally  accepted.  This  can  be  readily 
comprehended  when  it  is  understood  that  the  fibres  of  the  optic  tract 
originating  in  the  right  hemisphere  go  to  the  left  half  of  each  retina, 
and  that  the  optic  tract  which  arises  from  the  left  hemisphere  supplies 
the  right  half  of  each  retina  (Fig.  27,  page  346). 


SYMPTOMATOLOGY   OF   CEREBRAL   LESIONS.  341 

b.  Lesions  of  the  Anterior  Two- Thirds  of  the  Posterior  Half  of  the 

Internal  Capsule. 

Cerebral  Hemiplegia,  Secondary  Degeneration,  Late  Contraction. 
— Every  destructive  lesion  limited  to  the  anterior  two-thirds  of  the 
posterior  half  of  the  internal  capsule  causes  symptoms  of  common 
cerebral  hemiplegia,  otherwise  known  as  motor  paralysis,  and  affect- 
ing the  side  opposite  to  the  lesion.  When  the  lesion  is  situated  so  as 
to  involve  the  entire  posterior  half  of  the  internal  capsule,  we  have  at 
the  same  time  the  symptoms  of  motor  hemiplegia,  associated  with  the 
phenomena  of  ha?mi-ana3Sthesia  described  in  the  immediately  preced- 
ing section. 

A  motor  hemiplegia  consecutive  to  a  destructive  lesion  of  the  in- 
ternal capsule  is  in  general  very  decided,  and  more  or  less  persistent 
in  character.  Moreover,  at  an  advanced  stage  it  is  almost  invariably 
complicated  with  permanent  contractions  of  the  paralyzed  limbs,  as 
happens  in  profound  lesions  of  the  motor  zone  of  the  convolutions  and 
of  the  subjacent  white  substance.  These  contractions  are  directly  due, 
as  already  stated,  to  secondary  degeneration  of  the  pyramidal  motor 
fibres,  which,  crossing  from  the  fronto-parietal  region  of  the  centrum 
ovale  of  each  hemisphere,  reach  without  interruption  the  posterior  part 
of  the  lateral  column  of  the  spinal  cord  of  the  opposite  side  and  the 
anterior  column  of  the  same  side  by  passing  through  the  two  anterior 
thirds  of  the  posterior  half  of  the  internal  capsule. 

.  The  appearance  of  late  contractions  is  always  an  unfavorable  cir- 
cumstance in  determining  the  prognosis.  It  indicates,  in  fact,  that 
the  hemiplegia  is  due  to  a  lesion  of  the  internal  capsule,  and  that, 
moreover,  our  therapeutical  measures  are  generally  powerless  against 
the  hemiplegia  which  has  resulted.  At  the  same  time  it  is  not  to  be 
doubled  that  even  in  these  cases  ameliorations  can  be  sometimes  pro- 
duced by  appropriate  treatment. 

c.  Lesions  of  the   Central  Ganglia  of  the  Hemispheres. 

Transitory  Hemiplegia. — Lesions  confined  in  the  central  ganglia 
of  the  hemispheres  (lenticular  nucleus,  nucleus  caudatus,  and  optic 
thalamus)  also  produce  motor  paralysis.  Bui  this  is,  in  general,  of 
a  transienl  character,  and  is  probably  never  followed  l>\  late  contrac- 
tions. 

To  explain  the  non-permanent  duration  of  a  hemiplegia  confined  to 
the  gray  nuclei  of  the  hemispheres,  it  has  been  said  that  the  different 
parts  of  these  centres  can  replace  each  other  in  function.  Would  it 
not,  however,  be  more  natural  to  admil  thai  the  central  ganglia  do  not 

take  a  direcl  pari  in  the  executi >f  voluntary  movements?     On  the 

one  side  it  i-  demonstrated  thai  the  motor  zone  of  the  convolutions 
originates  voluntary  motor  impulses,  and  is  directly  in  anatomical  re- 


342  DISEASES  OF  THE   BRAIN. 

lation  with  the  motor  centres  of  the  spinal  cord.  On  the  other  side, 
there  is  no  case  on  record  in  which  a  lesion  limited  to  the  substance 
of  one  of  these  gray  nuclei  has  given  rise  to  secondary  degeneration. 
On  the  contrary,  Ttirck  has  noticed  a  lesion  the  size  of  a  filbert  seated 
in  the  body  of  the  nucleus  caudatus  which  had  not  produced  a  sec- 
ondary degeneration.  In  two  other  cases  reported  by  Ttirck,  a  lesion 
of  old  date  occupied  the  superior  part  of  the  optic  thalamus,  and  in 
neither  of  them  was  there  secondary  degeneration.  This  absence  of 
secondary  degeneration  has  likewise  been  noted  by  Flechsig  in  two 
cases,  in  which  a  circumscribed  lesion  was  limited  to  the  external  zone 
of  the  lenticular  nucleus.  The  central  ganglia  of  the  hemispheres 
seem,  then,  to  be  deprived  of  all  direct  connection  with  the  direct 
pyramidal  fibres  interposed  between  the  cortical  motor  zone  and  the 
motor  cells  of  the  spinal  cord. 

Moreover,  to  explain  the  development  of  transient  motor  hemiple- 
gia consecutive  to  lesions  in  the  substance  of  the  central  ganglia, 
we  are  led  to  admit  that  these  lesions  act  only  by  compression  in 
abolishing  for  a  short  time  the  functions  of  the  pyramidal  fibres  of 
the  internal  capsule  whose  office  it  is  to  transmit  voluntary  motor 
impulses. 

Hemi-mobile  Spasm  of  Cerebral  Origin. — A  few  years  since,  Dr. 
Weir  Mitchell  pointed  out  for  the  first  time  that  choreiform  troubles 
sometimes  complicate  the  muscular  paralysis  in  patients  who  have 
for  some  time  been  the  subjects  of  hemiplegia.  He  gave  to  this 
condition  the  name  of  post-hemiplegic  chorea.  More  recently  M. 
Charcot  has  shown  the  frequent  co-existence  of  hemichorea  with 
hsemi-anaesthesia  of  cerebral  origin.  Explaining  this  co-existence  by 
the  results  of  a  certain  number  of  autopsies,  he  has  demonstrated  that 
the  lesions  which  cause  these  two  varieties  of  phenomena — haemi- 
ansesthesia  and  hemichorea — occupy  contiguous  points  of  the  posterior 
part  of  the  foot  of  the  corona  radiata — the  lesions  which  have  been 
found  at  the  autopsy  of  patients  affected  with  hemichorea  being  com- 
prised in  the  zone  which  includes  the  posterior  part  of  the  internal 
capsule,  the  posterior  part  of  the  optic  thalamus  and  of  the  caudated 
nucleus,  and  the  anterior  tubercula  quadrigemina.  But  M.  Charcot  is 
of  the  opinion  that  the  lesion  of  the  white  substance — that  is  to  say, 
of  the  internal  capsule — is  that  to  which  the  hemichorea  supervening 
in  hemiplegia  is  to  be  ascribed  ;  and  this  view  is  likewise  held  by  the 
majority  of  neurologists,  but  it  seems  to  me  to  be  erroneous,  and  that 
the  true  lesion  is  of  an  irritative  nature  and  is  seated  within  the  basal 
ganglia.  Hemichorea,  hemiathetosis,  hemiparalysis  agitans,  and  all 
other  forms  of  hemi-mobile  spasms  differ  from  each  other  in  degree 
only,  and  not  in  nature.  It  is  to  be  remembered  that  this  hemispasm 
is  not  always  post-hemiplegic,  but  that  it  may  precede  an  attack  of 
cerebral  haemorrhage. 


SYMPTOMATOLOGY   OF   CEREBRAL   LESIOXS.  343 

d.  Lesions  of  the  Lateral  Ventricles  /  Ventricular  Haemorrhage. 

Convulsions  of  Central  Origin — Early  Contraction. — "When  a 
hemorrhagic  extravasation  breaks  through  into  the  cavity  of  the  ven- 
tricles, it  occasions  at  the  same  time  coma,  paralysis,  early  contrac- 
tions, and  epileptiform  convulsions. 


III. 

LESIONS    OF   THE   TUBERCULA    QirADRIGEMINA — OCULO-PL'PILLARY 

TROUBLES. 

It  is  generally  admitted  that  the  tubercula  quadrigemina  have  no 
connection  with  the  visual  sense.  The  influence  of  the  anterior  pair 
of  these  organs  over  the  movements  of  the  pupil  has  been  thoroughly 
demonstrated.  Flourens,  for  instance,  obtained  movements  of  the  iris 
on  both  sides  by  exciting  the  tubercula  quadrigemina  ;  and,  more  re- 
cently, Ferrier,  by  electrizing  these  nuclei  of  gray  substance,  has  seen 
the  pupils  dilate. 

In  addition,  the  anterior  pair  of  the  tubercula  quadrigemina  preside 
over  the  conjugate  movements  of  the  eyeballs.  This  is  shown  clearly  by 
the  researches  of  Adamiik,  published  in  1870.  This  physiologist  has 
shown  that  the  superficial  excitation  of  the  anterior  pair  of  the  tuber- 
cula quadrigemina  at  different  points  produces  varied  movements,  but 
that  always  both  eyes  move  simultaneously.  When  the  right  tuber- 
culum  is  excited,  both  eyes  deviate  to  the  left ;  when,  on  the  other 
hand,  the  left  is  excited,  both  eyes  are  turned  to  the  right. 

These  physiological  data  have  found  their  application  in  the  pa- 
thology of  the  nervous  system.  In  a  certain  number  of  cases  of  the 
destruction  of  the  tubercula  quadrigemina  of  both  sides,  complete 
blindness  with  dilatation  of  the  pupils  lias  been  produced.  Thus,  in 
the  case  of  a  patient  observed  in  the  service  of  M.  Pidoux  by  M.  Blan- 
quinque,1  and  in  which  during  life  complete  blindness  and  dilatation 
of  the  pupils  were  present,  at  the  autopsy  was  found   a   tumor  of  the 

pineal  gland,  which  compressed  both  pairs  of  tubercula  quadrigemina, 
especially  the  posterior  pair.      In    the  same  patient    the  eyes   were 

turned  downward   and  to  the  right.      This   phenomenon  of   the  conju- 
gate deviation  of  the  eyes  i^  also  observed  as  a  consequence  of  lesions 

affecting   very  different    points  of   the   nervous   centres.      It  is  of  such 

great    importance   in    its   diagnostic   relations   to   encephalic   lesions 

that    the   study    of    it>   semeiological    value    may    properly    engage    our 
attention. 

Conjugate  Deviation  of  the  Eyes. — Before  Adamiik  discovered  in 

the  two  anterior  tubercula  quadrigemina  the  centres  for  the  m 

1  Oazittr  hebdomadaire,  S<>.  :;::,  1871. 


344  DISEASES   OF  THE   BRAIN. 

ments  of  the  eyeballs,  Magendie  Lad  established  the  fact  that  these 
movements  are  under  the  influence  of  the  middle  cerebellar  peduncles. 
This  illustrious  physiologist,  having  divided  in  a  hare  the  middle  cere- 
bellar peduncle  of  one  side,  saw  the  corresponding  eye  turn  downward 
and  become  more  prominent,  while  the  eye  of  the  sound  side  turned 
upward  and  retreated  within  the  orbit.  The  eyes  resumed  their  nor- 
mal positions  as  soon  as  Floureus  divided  the  middle  cerebellar  pedun- 
cle of  the  other  side.  Longet  and  Schiff,.  on  repeating  Flourens's  ex- 
periment, arrived  at  a  like  result.  This  last  observer  noticed  that, 
when  the  experimental  lesion  involved  not  only  the  cerebellar  pedun- 
cle but  the  lateral  region  of  the  cerebellum,  the  conjugate  deviation 
was  still  produced,  but  with  an  inverse  disposition  ;  that  is,  the  eye  of 
the  sound  side  protruded  and  was  turned  downward,  while  the  eye  of 
the  injured  side  became  less  prominent  and  turned  upward.  A  simi- 
lar fact  had  already  been  observed  in  1826  by  Hertwig. 

More  recently,  Curschmann  has  contended  that  the  conjugate  de- 
viation of  the  eyes,  such  as  had  been  observed  by  Flourens,  is  not  the 
result  of  section  of  the  cerebellar  peduncles,  and  that  this  devia- 
tion is  only  produced  if  the  lesion  concerns  a  point  in  the  hemi- 
spheres of  the  cerebellum,  which  in  the  hare  is  known  as  the  acoustic 
tubercle. 

Hitzig,  who  experimented  on  rabbits,  obtained  conjugate  deviation 
of  the  eyes  by  applying  the  two  poles  of  a  galvanic  pile  to  the  poste- 
rior lobe  of  the  vermis.  Both  eyes  deviated  to  the  right  or  to  the 
left  according  as  the  positive  pole  was  applied  to  the  right  or  the  left. 
When  the  two  electrodes  came  in  contact  on  the  superior  lobe  of  the 
vermis,  one  of  the  eyes  turned  upward  and  the  other  downward,  ac- 
cording to  the  direction  of  the  current. 

Finally,  Ferrier  has  seen,  when  the  most  anterior  part  of  the  ver- 
mis was  electrically  excited,  both  eyes  deviate,  that  of  the  right  side 
outward,  and  that  of  the  left  inward.  By  exciting  the  middle  or  in- 
ferior part  of  the  vermis,  the  character  of  the  deviation  was  reversed. 
By  exciting  the  cerebellum  at  various  points  in  the  monkey,  the  dog, 
and  the  cat,  Ferrier  was  constantly  able  to  produce  conjugate  devia- 
tion of  the  eyes,  the  direction  of  the  deviation  varying  according  to 
the  point  excited.  In  general  terms,  it  may  be  said  that  the  organs, 
the  excitation  of  Avhich  produces  the  phenomenon  in  question,  are  the 
tubercula  quadrigemina  and  the  cerebellum  and  its  expansions. 

Moreover,  we  see  that  unilateral  lesions  of  any  point  whatever  of 
these  organs  are  equally  accompanied  by  conjugate  deviation.  In 
fact,  if  the  ocular  globes  are  cut  off  from  the  influence  of  one  of  the 
two  homologous  centres  which  preside  over  their  associated  move- 
ments, the  influence  of  the  unaffected  centre  will  alone  be  felt,  and  the 
two  eyes  will  take  the  same  anomalous  position  that  would  be  pro- 
duced by  excitation  of  a  symmetrical  point.  Clinical  experience  fully 
justifies  these  physiological  deductions.     For  a  long  time  it  has  been 


SYMPTOMATOLOGY   OF   CEREBRAL  LESIONS.  345 

known  that  lesions  situated  in  the  vicinity  of  the  isthmus  of  the  en- 
cephalon  cause  during  life  hemiplegia,  with  conjugate  deviation  of  the 
eyes,  accompanied  often  with  a  rotation  of  the  head  on  its  axis.  In 
regard  to  the  direction  of  the  deviation,  it  is  variable,  sometimes  be- 
ing toward  the  side  on  which  the  lesion  is  situated,  and  sometimes 
toward  the  opposite  side.  But  this  phenomenon  of  the  conjugate  de- 
viation of  the  eyes,  with  or  without  rotation  of  the  head,  is  observed 
in  the  cases  of  lesions  affecting  very  different  parts  of  the  cerebral  hemi- 
spheres. Very  often  the  phenomenon  is  due  to  a  restricted  lesion  in 
the  vicinity  of  the  corpus  striatum  and  peduncular  expansion.  M.  Pre- 
vost *  has  endeavored  to  lay  down  a  general  law  to  the  effect  that,  in 
a  case  of  cerebral  lesion,  the  conjugate  deviation  of  the  eyes  is  always 
from  the  affected  side.  But  a  case  reported  by  Duplay,  and  four  oth- 
ers by  Eichhorst,  demonstrate  that  the  contrary  direction  may  exist, 
and  that  consequently  the  rule  enunciated  by  Prevost  is  too  absolute. 

IV. 

LESIONS    OF   THE    OPTIC    TRACTS. 

Lateral  Hemianopsia. — As  we  have  seen,  according  to  the  theory 
generally  admitted,  the  nerve-fibres  which  form  the  0£>tic  nerves  only 
partially  decussate  in  the  chiasma.  Those  which  cross  over  from  one 
side  to  the  other  are,  of  course,  the  nearest  to  the  median  line,  and 
occupy  the  most  internal  part  of  the  nerve  and  optic  tract  of  each  side. 
On  the  other  hand,  those  fibres  which  do  not  cross  occupy  the  most 
external  part  of  the  nerve  and  tract.  An  examination  of  the  draw- 
ing (Fig.  27)  will  make  these  statements  clear,  and  will  establish  the 
fact  that  the  nerve-fibres  which  form  each  tract  pass  to  the  correspond- 
ing half  of  each  retina.  Thus  the  fibres  of  the  left  optic  tract  pass  to 
tlie  left  half  of  each  retina,  and  those  of  the  right  to  the  right  half. 

This  explanation  of  the  course  of  the  fibres  of  the  optic  nerves  be- 
tween the  retina  and  the  eortex  enables  us  to  perfectly  understand  the 

different  forms  of  hemianopsia  due  to  lesions  of  the  optic  tracts. 

Thus  homonymous  lateral  hemianopsia — that  is  t<>  say,  sensorial 
paralysis  of  1  he  same  half  of  each  retina    has  been  observed  in  a  great 

Dumber  of   eases  in  which    the    lesion    affected    one  of   the   optic   tracts 

either  < I i n-'t  1  \  or  indirectly  by  the  intermediation  of  neighboring  or- 
gans.    Now  the  theory  given  unqualifiedly  requires  that  when  a  1< 

destroy  -  the  Optic  tract  of  the  left  side,  only  the  left  half  of  each  retina 
will  be  deranged  in  its  position,  and  inversely  if  the  lesion  i<  situated 
on   the  right   side. 

The  resulting  hemianopsia  may  be  confined  to  one  retina  when  a  uni- 
lateral hsi< nly  affects  the  mosl  external  fibres  (homonymous  hemi- 
anopsia) orthe  most  interna]  (crossed  hemianopsia)  of  one  of  the  optic 

tracts. 

1  "  Do  hi  deviation  conjuguie  des  yeux."     Th&at  th  Paris,  1S68. 


346 


DISEASES   OF   THE   BRAIN". 


"When  a  circumscribed  lesion  is  situated  in  the  anterior  angle  of 
the  chiasma,  so  that  its  action  is  limited  to  the  most  internal  of  the 


Fig.  27. 


Diagram  of  the  relation  of  the  fields  of  vision,  retina,  and  optic  tracts.  (Gowers.) 
RF,  LF,  right  and  left  fields;  the  asterisk  is  at  the  fixation-point.  R  R,  L  R,  right  and 
left  retina;  the  asterisk  is  at  the  macula  lutea.  Ih,  r  k,  left  and  right  half  of  each 
retina,  receiving  rays  from  the  opposite  halves  of  the  fields.  R  N,  L  N,  right  and 
left  optic  nerves.  Ch,  chiasma.  E  T,  L  T,  right  and  left  optic  tracts;  below  are  the 
superimposed  halves  of  the  fields  from  which  impressions  pass  by  each  optic  tract. 

fibres  of  the  optic  nerves,  the  result  should  be  a  temporal  hemianopsia. 
In  other  words,  in  accordance  with  the  theory,  the  visual  trouble  should 
be  limited  to  the  internal  half  of  each  retina.  Saemisch  has  published 
a  case  of  this  kind,  in  which  the  diagnosis  of  the  seat  of  the  lesion 
was  marie  during  the  life  of  the  patient. 

Finally,  in  order  that  there  should  be  a  nasal  hemianopsia — that  is, 
that  the  visual  trouble  should  be  limited  to  the  external  half  of  each 
retina— it  is  necessary  that  a  bilateral  and  symmetrical  lesion  should  affect 
only  the  external  part  of  each  optic  tract.  This  has  been  demonstrated 
by  several  cases  ;  among  others,  by  those  of  Knapp,  published  in  1873. 


SYMPTOMATOLOGY   OF   CEREBRAL   LESIOXS. 


347 


V. 

LESIONS  OF  THE  CEREBRAL  AND  CEREBELLAR  PEDUNCLES. 

a.    Crura  Cerebri. 

The  crura  cerebri  contain  in  their  substance  all  the  sensory  and 
motor  fibres  which  connect  the  periphery  with  the  encephalic  centres. 
Two  parts,  or  strata,  are  to  be  distinguished  in  these  organs,  separated 
from  each  other 
by  the  substan- 
tia nigra.  The 
inferior  part  con- 
tains the  motor 
fibres  which  pass 
from  the  gray 
cortex  of  the 
hemisphere  to 
the  spinal  gan- 
glia, and  also 
fibres  which  ap- 
pear to  connect 
the  cerebrum 
with  the  cere- 
bellum. The  su- 
perior part  con- 
tains the  sen- 
sory tract  and 
some  of  the  cra- 
nial nerve-cen- 
.tres  and  their 
fibres.  The  « 1  i — 
rect  motor-tract 
fibres  are  sit u- 
ated  in  the  mid- 
dle third  of  the  crusta  (Fig.  28),  while  in  the  sensory  division  the 
fibres  transmitting  muscular  sense  are  to  he  found  in  the  lemniscus, 
and  those  conducting  other  sensory  impressions  in  the  formatio  reticu- 
laris.    As  the  facial  nerve  does  not  decussate  until  the  lower  border 

of  the  pons  ia  reached,  a  lesion  in  the  pyramidal  tract  of  one  cms  will 

produce  hemiplegia  on  the  opposite  Bide  of  the  body.  Lower  down, 
however,  after  the  decussation  of  the  facial  nerves  a  unilateral  lesion 
of  the  motor  trad  results  in  paralysis  of  the  face  on  the  side  of  the 
lesion  and  paralysis  of  the  arm  and  leg  on  the  opposite  side. 

A  Lesion  of   the   lemniscus    LS    followed    by  unilateral    ataxia  on    t!..- 

opposite  Bide. 

A-  the  sensory  division  of  the  trigeminus  decussates  at  the  upper 


Diagram  of  section  of  crus.  (Modified  from  Ctowcts.) 
L  F,  C  F,  lower  and  upper  fillet  or  lemniscus.  F  R,  formatio  reticu- 
laris. C  Q  A,  anterior  corpora  quadrigemina.  Aq,  aqueduct. 
III.  nucleus  of  third  nerve.  V  II.  posterior  horizontal  fibres. 
Cpt  brachium  of  post.  corp.  quad.  R  N,  red  nucleus,  s  X.  sub- 
stantia nigra.  CGI,  internal  geniculate  body.  TOC,  temporo- 
tal  cerebellar  fibres.  Pyy  pyramidal  fibres.  F,  fibres  from 
the  face.  A,  fibres  from  the  arm.  L,  fibres  from  the  leg.  FC, 
fronto-cerebellar  fibres.  C  C,  caudate  cerebellar  fibres,  t,  Inner 
fibres  of  crusta  to  tegmentum. 


348  DISEASES   OF   THE   BRAIN. 

border  of  the  pons,  a  lesion  of  the  formatio  reticularis  would  result  in 
annesthesia  of  the  face  on  the  same  side  as  the  lesion  and  anaesthesia  of 
the  opposite  arm  and  leg,  but  a  lesion  confined  to  the  sensory  area  of 
one  cms  would  induce  hemi-anassthesia  on  the  opposite  side  of  the 
body. 

Sometimes  the  third  pair  of  nerves  is  affected,  and  then  paralysis 
of  the  muscls  of  the  eyeball  supplied  by  it  complicates  the  paralysis  of 
the  muscles  of  the  opposite  side. 

b.   Cerebellar  Peduncles. 

Cm*schmann  has  recently  published  the  case  of  a  tuberculous 
woman,  who  complained  of  vertigo  and  headache  followed  by  con- 
vulsive seizures,  at  the  end  of  which  she  fell  on  the  right  side.  At 
the  autopsy  there  was  found  a  tuberculous  meningitis,  and  a  focus  of 
softening  on  the  right  side  involving  the  anterior  and  posterior  cere- 
bellar peduncles.  The  same  author  has  already  proven  by  experi- 
ments that,  if  a  cerebellar  peduncle  of  one  side  be  divided,  the  animal 
is  at  once  seized  with  convulsions,  and  falls  on  the  side  corresponding 
to  the  lesion. 

More  recently  Coutry '  has  published  the  case  of  a  man  who  pre- 
sented, as  his  only  symptoms,  obstinate  vomiting  and  motor  ataxia  as 
regarded  certain  movements.  These  latter  were  jerking  and  sudden. 
At  the  autopsy  of  this  man,  who  died  of  tubercular  meningitis,  there 
was  found  entire  destruction  of  the  left  inferior  cerebellar  peduncle. 


CHAPTER  XVIII. 

SYMPTOMATOLOGY  OF  CEREBELLAR  DISEASES. 

The  pathology  of  the  cerebellum  is  as  yet  imperfectly  understood. 
This  is  due,  in  the  first  place,  to  the  insufficiency  of  our  knowledge  of 
the  functions  of  this  organ,  and,  in  the  next,  to  the  fact  that  very  pro- 
found lesions  may  be  situated  in  the  cerebellum,  and  may  even  destroy 
it  in  great  part,  without  causing  the  least  functional  disturbance  ;  while 
circumscribed  lesions  engender  symptoms  very  variable  in  character, 
and  due  for  the  most  part  to  compression  of  contiguous  organs. 

These  symptoms  are,  moreover,  similar  to  those  which  result  from 
lesions  of  the  most  varied  of  the  nerve-centres.  It  is  only  the  manner 
in  which  they  are  grouped  together,  and  their  greater  or  less  frequency, 
which  enables  us  to  diagnosticate  with  some  degree  of  assurance  that 
the  lesion  from  which  they  result  is  in  reality  situated  in  the  cere- 
bellum. 

1  ComjAcs  rendus  de  la  Sociite  de  Biologie,  seance  du  5  Mai,  1877. 


SYMPTOMATOLOGY   OF   CEREBELLAR   DISEASES. 


349 


Chief  among  them  must  be  placed — 

(a.)  Headache,  vomiting,  and  vertigo  ;  phenomena  that  are  ob- 
served very  often  in  circumscribed  lesions  of  the  encephalon,  whatever 
may  be  their  seat,  but  which  are  met  with  more  frequently  in  casts 
in  which  they  are  located  in  the  cerebellum. 

(b.)  Titubation  ;  a  symptom  which  by  some  physiologists  is  as- 
signed to  derangement  of  the  coordinating  faculty  which,  according 
to  them,  resides  in  the  cerebellum. 

(c.)  Motor  excitations  under  the  form  of  epileptic  convulsions. 

(d.)  Motor  paralyses,  which,  however,  generally  consist  of  feeble- 
ness, and  not  complete  loss  of  power  in  the  limbs. 

(<?.)  Sensorial  troubles,  such  as  those  of  sight  and  hearing. 

(f.)  There  are  also  to  be  noticed,  in  the  course  of  cerebellar  affec- 
tions, derangement  of  the  faculty  of  speech,  and  paralyses  of  the  face 
and  of  certain  muscles  of  the  eye  ;  symptoms  which  are  due  to  the 
compression  of  contiguous  organs,  such  as  the  cerebellar  peduncles, 
the  bulb,  etc.  [To  this  must  be  added  that  peculiar  oscillatory  mo- 
tion of  the  eyeballs,  called  nystagmus,  a  phenomenon  rarely  absent  in 
cases  of  cerebellar  disease. — W.  A.  H.] 

The  following  table  shows  at  a  glance  the  relative  frequency  of 
the  several  symptoms  of  cerebellar  diseases.  It  is  made  up  from  cases 
adduced  by  some  among  the  most  eminent  of  those  who  have  studied 
the  subject : 


SYMPTOMS. 


Occipital  headache 

Frontal  "        

General  "        

Vomiting       "       

Troubles  of  motility 

Progressive  feebleness  of  the  muscles 

Uncertainty  of  gait 

Hemiplegia 

Paraplegia 

Btrabismus 

paralysis 

Predominance  of  action  on   one   side  of  the 

body 

Tremor 

Epileptiform  convulsions 

Derangement  -  of  —  i  >••■-«•  1 1 

Amblyopia — amaurosis 


Duohek, 
15  cases. 


8  I 


lii 


in 


Ladane, 
66  cases. 


27 
11  V 
18 

54 

2 

16 

7 
2 


4 
1 

28 


Ollivier  and 

Leveii,  T6 

cases 


31 
3  V41 


71 

17 

9 


25 
13 


Lays.  10) 
cases. 


25  1 
6-50 

19) 

35 


45 
28 

16 

7 


5 

7 

L2 

20 

18 


Some  writers  have  attached  a  certain  diagnostic  importance  t<>  the 
absence  in  cerebellar  diseases  of  anaesthesia  and  troubles  <>f  general 
sensibility.  Nevertheless,  Drozda,'  of  ninety-five  cases  of  cerebellar 
affections  collected  by  himself,  found  thai   in  fifteen  then'  were  modi- 


1  "Wiener  med,  Wochensohrift,"  1876,  p.  ISO 


350  DISEASES   OF  THE   BRAIN. 

fications  of  the  general  sensibility,  not  including  headache  among  the 
number. 

On  the  other  hand,  the  cerebellum  having  been  for  a  long  time  con- 
sidered as  the  centre  for  the  coordination  of  movements  and  of  the  mus- 
cular sense,  the  presence  of  motor  incoordination  and  the  abolition  of 
the  muscular  sense  have  been  regarded  as  the  two  pathognomonic  signs 
of  cerebellar  lesions.  Clinical  observation  has  demonstrated  the  in- 
correctness of  this  view.  Muscular  sensibility  has  been  found  to  re- 
main intact  during  the  existence  of  lesions  of  the  organ  in  question, 
and  incoordination  is  a  symptom  peculiar  to  locomotor  ataxia,  the 
lesion  of  which  exists  in  that  portion  of  the  spinal  cord  in  which  the 
radicles  of  the  posterior  nerve-roots  are  situated.  In  the  cases  of  per- 
sons suffering  from  cerebellar  disease  the  gait  is  vacillating  and  titubat- 
ing, like  that  of  a  drunken  individual  ;  and  the  symptom  is  as  well- 
marked  when  the  patient  walks  with  his  eyes  open  as  when  he  has 
them  shut.  There  is  not  in  these  lesions  that  absence  of  harmonious 
muscular  action  that  is  observed  in  ataxics. 

Nevertheless,  Huppert 1  has  quite  recently  published  a  case  of  atro- 
phy of  the  cerebellum  in  an  individual  whose  lower  extremities  were 
affected  very  much  as  are  those  of  patients  suffering  from  locomotor 
ataxia.  To  the  uncertain  and  titubating  gait  are  added  often  motor 
troubles  similar  to  those  which  ensue  in  animals  who  have  been  sub- 
jected to  experimental  lesions  of  the  cerebellum  and  its  peduncular  ex- 
pansions. There  are  irresistible  impulsions  forward  or  backward,  and 
a  like  tendency  to  turn  continually  toward  the  same  side;  sometimes, 
also,  the  patients  are  unable  to  stand. 

Another  characteristic  of  cerebellar  lesions  is  the  rapidity  with 
which,  in  the  great  majority  of  cases,  the  ultimate  phenomena  super- 
vene. Contrary  to  the  course  of  a  great  number  of  cerebral  lesions, 
the  beginning  is  insidious,  and  the  fatal  termination  often  supervenes 
in  an  unexpected  and  sudden  manner. 

On  the  whole,  we  are  led  to  diagnosticate  a  cerebellar  lesion 
when  we  find  united  in  the  same  patient  a  certain  number  of  the  fol- 
lowing phenomena  :  Occipital  headache  with  nervous  vomiting,  ver- 
tigo, a  staggering  and  uncertain  gait,  Aveakening  of  the  muscular 
power  without  ataxia,  amblyopia,  amaurosis,  and  an  irresistible  ten- 
dency to  turn  over  toward  one  side.  [In  this  connection  I  may  be  ex- 
cused for  quoting  from  a  paper,2  to  which  reference  has  already  been 
made  in  other  parts  of  the  work,  the  following  conclusions  based  on 
original  experiments,  and  which  have  a  bearing  upon  the  subject  of 
cerebellar  disease  : 

"  1.  The  consequences  of  removal  of  the  cerebellum,   if  the  ani- 

1  "  Arcliiv  fur  Psychiatric,"  B.  vii.,  1811,  p.  91. 

2  "  The  Physiology  and  Pathology  of  the  Cerebellum,"  Quarterly  Journal  of  Psycho^ 
logical  Medicine,  January,  1809,  p.  209. 


SYMPTOMATOLOGY   OF   CEREBELLAR   DISEASES.  351 

raal  survives  the  immediate  effects  of  the  operation,  are  not  endur- 
ing. 

"  2.  The  entire  removal  of  the  cerebellum  from  some  animals  does 
not  apparently  interfere  in  the  slightest  degree,  even  for  a  moment, 
with  the  regularity  and  order  of  their  movements. 

"  3.  The  disorder  of  movements,  which  results  in  birds  and  mam- 
mals immediately  after  injury  of  the  cerebellum,  is  not  due  to  any  loss 
of  coordinating  power,  but  is  the  result  of  vertigo. 

"4.  The  phenomena  of  cerebellar  disease  or  injury,  as  exhibited  in 
man, are  not  such  as  show  any  derangement  of  the  coordinating  power. 

"  5.  In  those  diseases  of  which  the  chief  phenomena  relate  to  de- 
rangement of  the  coordinating  power,  the  lesion  is  not  in  the  cerebel- 
lum, and  the  symptoms  are  altogether  different  from  those  due  to  cere- 
bellar disease  or  injury." — W.  A.  H.] 

The  principal  lesions  which  may  affect  the  cerebellum  are  tumors, 
haemorrhage,  softening,  and  sclerosis,  which  latter  sometimes  terminates 
in  atrophy  of  the  organ. 


TUMORS    OF   THE    CEREBELLUM. 

The  cerebellum  may  be  the  seat  of  tumors  of  very  different  natures. 
Thus  there  are  aneurisms  or  vascular  tumors,  parasitic  tumors  (cysl  icerci 
echinococci),  cancerous  tumors,  tubercles,  syphilitic  gummata,  sarco- 
mata, lipomata,  etc. 

It  is  rarely  the  case  that  tumors  arc  situated  in  the  cerebellum  with- 
out the  neighboring  parts  being  more  or  less  affected  by  compression. 
Thus  it  is  that  the  different  instances  which  have  been  reported  pre- 
sent variable  groups  of  symptoms  one  from  the  other  ;  and  in  the  future 
it  will  he  necessary  to  separate  with  more  exactness  than  has  yet  been 
done  the  phenomena  which  are  the  results  of  lesions  of  the  cerebellum 
from  those  which  are  due  to  the  compression  of  contiguous  organs. 

Ordinarily  those  patients  in  whom,  on  post-mortem  examination,  a 
tumor  baa  been  found  in  the  cerebellum,  have  presented,  as  an  initial 
symptom,  pain,  generally  in  the  occipital  region,  accompanied  with 
nausea  and  obstinate  vomiting.  S er  or  later  come  troubles  of  mo- 
tility, consisting  of  titubati the  impossibility  of  standing  erect,  a 

tendency  to  roll  over  toward  one  side  or  the  other,  epileptiform  con- 
vulsions, and  general  muscular  weakness,  which  does  not,  however, or- 
dinarily reach  the  extent  of  actual  paralysis.  Statistics  show  that,  in 
a  large  number  of  oases,  individuals  affected  with  cerebellar  disease 
have  exhibited  some  form  of  circumscribed  paralysis,  either  of  the  hemi- 
plegia or  paraplegic  form.  Bui  such  phenomena  must,  in  general,  be  as- 
cribed to  compression  ex<  rcised  on  the  motor  fibres  which  pa^s  through 


352  DISEASES  OF  THE  BRAIN. 

the  cerebral  peduncles,  the  protuberance,  and  the  bulb,  by  a  tumor 
situated  in  the  vicinity  of  the  isthmus  of  the  encephalon.  Derange- 
ment of  the  faculty  of  speech  and  tremors  of  the  tongue  and  lips  have 
also  been  noticed  in  a  large  number  of  cases  of  tumor  of  the  cerebel- 
lum ;  and  amblyopia,  reaching  to  the  point  of  extreme  blindness,  is  also 
a  very  common  symptom.  M.  Raymond1  has  reported  a  case  of  a 
woman,  twenty-seven  years  old,  at  whose  post-mortem  examination  a 
tumor  was  found,  the  size  of  a  hen's  egg,  which  was  situated  between 
the  two  lobes  of  the  cerebellum,  in  such  a  position  that  it  separated 
one  from  the  othrr,  so  that  the  superior  vermis  was  notably  flattened  by 
the  pressure.  The  anterior  extremity  reached  as  far  as  the  tubercula 
quadrigemina,  which  were  also  compressed.  Relative  to  the  position 
of  the  tumor  M.  Raymond  says  that  it  was  such  that  the  fourth 
ventricle  was  entirely  obliterated;  It  is  important,  in  view  of  the  pa- 
thogeny of  visual  troubles,  that  the  tubercula  quadrigemina  were 
entirely  destroyed,  and  that  the  optic  tracts  were  atrophied — facts 
which  sufficiently  account  for  the  amblyopia.  M.  Raymond  has  added 
the  abstracts  of  fifteen  other  cases  of  tumor  of  the  cerebellum,  accom- 
panied by  papillary  atrophy  with  amaurosis. 

From  the  comparison  of  these  different  cases,  we  are  warranted  in 
concluding  that  there  is  no  definite  connection  between  the  seat  of  a 
tumor  in  the  cerebellum  and  the  development  of  morbid  change  in  the 
optic  nerves.  We  know,  also,  that  atrophy  of  the  optic  nerves  is  met 
with  in  many  other  affections,  spinal  and  cerebral,  as  well  as  cerebel- 
lar. Of  sixty  cases  of  tumors  of  the  cerebellum,  collected  by  Maca- 
biau,2  forty  were  characterized  by  troubles  of  the  eyesight.  Generally 
these  consisted  of  a  more  or  less  complete  amaurosis,  the  result  of 
atrophy  of  the  optic  nerve.  In  other  cases  the  pupils  were  dilated  or 
contracted,  or  there  was  deviation  of  the  eyeballs  to  one  side  or  the 
other. 

We  therefore  perceive  that  the  symptomatology  of  tumors  of  the 
cerebellum  is  subject  to  great  differences — a  fact  which  renders  the 
diagnosis  very  difficult ;  and  the  fact  must  not  be  lost  sight  of,  that  a 
neoplasm  of  great  size  may  be  developed  in  the  cerebellum,  and  not  be 
manifested  by  any  symptom  during  the  life  of  the  patient,  only  being 
brought  to  light  in  post-mortem  examination. 

[A  very  interesting  case  of  tumor  of  the  cerebellum  has  recently 
been  published  by  Prof.  Diodato  Borrelli,  of  the  Royal  University  of 
Naples.  In  this  instance  there  were  numerous  sarcomatous  growths 
over  the  whole  surface  of  the  body,  and  after  death  similar  growths 
were  found  in  some  of  the  viscera,  the  spinal  cord,  the  cerebrum,  and 
notably  in  the  cerebellum.  The  compression  exerted  by  the  intra- 
cranial tumors  had  been  sufficient  to  flatten  the  optic   thalami   and 

1  Gazette  Medicate  de  Paris,  1871,  p  371. 

8  "Dcs  turneurs  du  cervclet,"  These  de  Paris,  1869. 


SYMPTOMATOLOGY   OF   CEREBELLAR   DISEASES.  353 

corpora  quadrigernina,  and  to  push  these  latter  out  of  their  normal 
position. 

Two  tumors  were  found  in  the  cerebellum  :  one,  on  the  left  hemi- 
sphere, the  size  of  a  hen's  egg  ;  the  other,  much  smaller,  was  situated 
on  the  periphery  of  the  right  lobe. 

But  it  is  not  so  much  to  the  morbid  anatomy  as  to  the  symptoms 
that  I  desire  in  this  connection  to  call  attention.  These  latter  were 
observed  with  great  care  ;  and  though,  of  course,  they  were  in  part 
due  to  compression  of  neighboring  organs,  they  do  not  differ  in  this 
respect  from  those  likely  to  result  in  all  cases  of  tumors  of  any  part 
of  the  encephalon. 

The  patient's  countenance  wore  an  expression  of  pain  ;  his  ryes 
were  from  time  to  time  seized  with  spasms,  during  which  they  turned 
in  all  directions  ;  his  gait  was  titubating  and  uncertain,  and  he  walked 
with  his  feet  far  apart,  so  as  to  increase  his  width  of  base  ;  there  was 
intense  vertigo  ;  the  headache  was  agonizing,  and  was  situated  in  the 
frontal  and  vertical  regions,  but  even  more  decidedly  in  the  occipital 
region  ;  vomiting,  which  was  persistent  and  unamenable  to  treatment, 
and  a  tormenting  pruritus,  were  also  present ;  and  there  were  tonic 
spasms  of  the  muscles  of  the  neck,  by  which  the  head  was  strongly 
rotated  to  the  right. 

The  visual  power  was  diminished,  though  not  equally,  in  both  eyes, 
and  the  hearing  was  similarly  affected.  The  other  special  senses  were 
not  deranged,  and  the  general  sensibility  of  the  body  was  apparently 
intact.  Neither  was  there  any  notable  impairment  of  muscular  power, 
though  the  lower  extremities  wrere  somewhat  more  affected  in  this 
way  than  the  upper.  As  to  the  mental  condition,  at  first  sight  it  ap- 
peared as  though  it  were  normal,  but  careful  observation  showed  that 
the  memory  was  weakened.1 — W.  A.  II.] 

II. 

il   BMOBBHAGSS    OF    TIIK    CEREBELLUM. 

M.  Hillairet,  who  was  the  first  to  study  haemorrhages  of  the  cere- 
bellum by  separating  them  from  these  occurring  in  other  parts  of  the 
body,  distinguishes  two  forms — the  one  sudden,  tin-  other  chronic  and 
of  -low  progress. 

In  the  sudden  form  the  patienl  i-  struck  with  :m  apoplectic  -hock, 

and  dies  comatose  at  the  end  of  a  short  time.  In  the  slow  form  the 
intelligence  remains  intact,  the  patient  complains  of  headache,  gener- 
ally in  the  occipital  region,  and  vomiting  i>  very  frequent.     The  other 

1  Dr.  Borrelli  follows  lii-  account  <>f  tlii-  Interesting  case  with  .1  very  full  bibliography 
of  t!i>'  literature  of  cerebellar  tumors,  and  :i  thoroughly  well-digested  and  critical  ■ 
upon  the  subject 


354  DISEASES   OF  THE   BRAIN. 

symptoms  consist  of  a  vertiginous,  titubating  gait,  and  a  general  weak- 
ness of  the  limbs,  difficulties  of  speech,  and  troubles  of  vision.  Hemi- 
plegia, which  has  been  considered  a  common  symptom  of  lesion  of 
the  cerebellar  substance  (Hillairet),  should  be  regarded,  according  to 
M.  Vulpian,  as  an  effect  of  the  compression  exercised  by  hemorrhagic 
centres  on  the  motor  fasciculi  of  the  isthmus  of  the  encephalon. 

On  the  whole,  the  symptoms  of  cerebellar  haemorrhage  are  the 
same  as  are  observed  in  tumors  of  this  organ,  with  the  exception  that 
their  evolution  is  much  more  rapid.  In  fact,  even  in  the  slow  form  of 
the  disorder,  it  is  rare  that  the  patient  survives  more  than  a  few  days. 


III. 

ATROPHY    OF    THE    CEREBELLUM. 

Atrophy  of  the  cerebellum,  when  it  is  not  congenital,  is  generally 
consecutive  to  sclerosis  of  that  organ.  It  can  not  be  recognized  by  any 
positive  symptom.  Sometimes  it  is  met  with  in  epileptics.  M.  Du- 
guet  has  reported  three  examples  of  this  condition.  In  a  case  of  very 
pronounced  atrophy  of  the  cerebellum,  in  a  young  man  twenty-two 
years  of  age,  Max  Huppert '  has  noticed  during  life  epileptiform  con- 
vulsions, choreiform  agitation  of  the  muscles,  with  diminution  of  mus- 
cular force,  difficulty  of  standing  erect,  titubation  during  walking,  and 
trouble  of  speech.  The  limbs,  which  were  not  paralyzed,  were  never- 
theless affected  with  incoordination  similar  to  the  same  symptom  as 
observed  in  ataxics. 

A  case  of  what  is  probably  sclerosis  and  atrophy  of  the  cerebel- 
lum was  for  several  years  under  my  observation,  and  was  presented 
by  me  before  the  American  Neurological  Association  at  its  meeting  in 
June,  1877.2 

The  patient,  a  boy  about  four  years  of  age,  was  brought  to  my 
clinique  at  the  University  Medical  College  in  January,  1870.  He  was 
apparently  in  good  health,  was  well  grown  for  his  age,  and  had  not 
been  subject  to  any  exhausting  disease.  As  he  sat  upon  a  chair,  he 
exhibited  no  indications  of  paralysis,  spasm,  or  incoordination.  He 
moved  both  legs  well  and  with  normal  force,  and  could  use  either 
hand  in  the  ordinary  way.  But  it  was  impossible  for  him  to  assume 
the  erect  posture,  and  when  he  attempted  to  do  so  he  stood  in  a  pecul- 
iar, one-sided,  stooping  position,  the  left  arm  being  strongly  flexed 
against  the  side  of  the  chest,  while  the  right  was  thrown  out  behind 
him.      He  could  not  maintain  himself  on  his   feet   without  support. 

1  "  Archiv  fur  Psychiatric  und  Nervenkrankhciten,"  B.  iii.,  p.  98. 

2  "On  a  Ilitherto  Undescrilx'd  Form  of  Muscular  Incoordination,"  " Transactions  of 
the  American  Neurological  Association,  1877." 


SYMPTOMATOLOGY   OF  CEREBELLAR  DISEASES. 


355 


Fig.  29. 


The  attitude  is  shown  in  the  accompanying  woodcut,  Fig.  29,  taken 
from  a  photograph. 

In  walking  he  was  able  to  direct  his  steps  with  a  certain  amount 
of  precision,  but  yet  not  to  a  normal  extent.  He  appeared  also  to 
have  more  difficulty  in  arresting  his  movements,  and  was  accordingly 
apt  to  come  up  violently  against  obstacles  which  were  in  his  way. 
His  gait  was  rather  a  run  than  a  walk,  and  he  often  fell.  In  bring- 
ing the  case  before  the  class  I  expressed  the  provisional  opinion  that  it 
was  one  of  chorea  paralytica,  but  further 
examination,  and  the  inefficacy  of  all  treat- 
ment, soon  caused  me  to  change  this  view. 

In  May  he  came  under  the  charge  of  a 
surgeon,  who  circumcised  him,  under  the 
impression  that  the  case  was  one  of  reflex 
incoordination.  It  is  scarcely  necessary  to 
say  that  the  operation  was  unsuccessful. 
When  he  appeared  before  the  Association, 
in  June,  there  had  been  a  gradual  advance 
in  the  intensity  of  his  symptoms.  Yet, 
notwithstanding  the  marked  incoordination, 
there  was  no  paralysis,  no  derangement  of 
sensibility,  no  bladder  disturbance,  no 
spasm,  no  diminution  of  electric  excitabil- 
ity of  the  muscles,  and  none  of  the  peculiar 
symptoms  indicative  of  sclerosis  of  any 
part  of  the  cord. 

After  this  there  was  a  short  intermission 
in  his  symptoms,  and  his  father  thought 
lie  was  recovering.  lie  wrote  me  to  that 
effect,  September  7th,  no  medicine  having 
been  taken,     lint  soon  afterward  he  again 

relapsed,  and  his  condition  gradually  became  worse.  When  I  last  saw 
him,  about  a  year  ago,  there  were  nystagmus  and  a  total  inability  to 
stand.      When  he  tried  to  do  so,  he  bent  over  till  his  head  touched  the 

floor,  and  thus  he  remained,  apparently  endeavoring  t<>  stand  on  his 
bead.  When  he  wished  to  ^<>  anywhere  in  the  room,  he  lay  down  on 
the  floor  and  rolled  toward  it,  turning  over  toward  the  left  always. 

About  this  time  Dr.  .1.  S.  Jewell,  of  Chicago,  saw  the  patient.  Con- 
tinued examination  and  study  of  this  very  interesting  case  lead  me  to 

the  opinion  that   it   is  in I'  sclerosis  and  atrophy  of  the  cerebellum. 

The  subjeol  of  the  diagnosis  of  diseases  of  the  brain   cannol   be 
passed  over  without  a  reference  to  the  masterly  work  of  Nothnagel' 

OD  the   subject,  even  if   that  reference  docs  not  go  further   than   citing 


"Topiscbe  Diagnostic  der  Qehirnknmkbdten  •  eine  klinische  Btudie,"  Berlin,  1879 


356  DISEASES  OF  THE  BRAIN. 

the  conclusions  at  which  he  arrives,  modified  by  the  light  that  more 
recent  investigation  has  thrown  on  the  subject. 

Cerebellum. 

"  1.  Diseases  of  the  cerebellum  may  remain  completely  latent,  and 
thus  be  incapable  of  being  diagnosticated.  This  is  generally  the  case 
with  destructive  lesions  situated  in  one  hemisphere. 

"  2.  Lesions  of  slight  extent  may,  on  the  other  hand,  present  a 
very  variable  and  complicated  appearance. 

"  3.  The  most  characteristic  symptoms  of  cerebellar  affections  are 
incoordination,  a  titubating  gait,  and  intense  vertigo.  These  symp- 
toms are,  however,  met  with  in  other  brain-diseases,  and  cannot,  there- 
fore, be  considered  pathognomonic.  It  is  by  a  consideration  of  all  the 
phenomena,  positive  and  negative,  that  the  diagnosis  of  cerebellar  dis- 
eases is  to  be  made. 

"  4.  Cerebellar  staggering  always  denotes  the  involvement  of  the 
middle  lobe,  whether  this  be  the  primary  situation  of  the  lesion  or  an 
implication  (functional  also)  through  pressure. 

"  5.  At  the  same  time,  incoordination  and  vertigo  may  be  absent 
in  diseases  of  the  cerebellum  situated  mainly  in  the  hemispheres,  as  is 
also  the  case  sometimes  with  tumors  the  seat  of  which  is  the  vermis. 
If  in  such  a  case  we  feel  justified  on  other  grounds  in  suspecting  the 
existence  of  a  lesion  in  the  posterior  encephalic  region  below  the  ten- 
torium, we  can  never,  with  any  approach  to  certainty,  diagnosticate 
the  existence  of  either  primary  or  secondary  diseases  of  the  cerebel- 
lum. Its  implication  under  such  circumstances  is  possible,  but  is  by 
no  means  a  matter  of  certainty. 

"  6.  In  addition  to  the  symptoms  given  under  section  3,  there  are 
some  others  which  can  be  considered  as  indicating  the  existence  of  a 
disturbance  of  the  functions  of  the  cerebellum,  and  hence  the  presence 
of  lesions  of  this  organ.  Perhaps  certain  derangements  of  speech 
(anarthia)  in  cases  of  extensive  atrophy  of  the  cerebellum  may  be  so 
regarded,  but  yet  there  is  no  surety  on  the  subject. 

"  7.  Vomiting,  when  constant  and  severe,  may  in  some  cases  sup- 
port the  diagnosis  of  a  cerebellar  disease,  but  it  is  not  conclusive  of 
such  a  condition,  for  it  is  often  an  accompaniment  of  other  encephalic 
affections.  It  is  lacking  in  all  cases  of  destructive  lesions,  and  is  not 
a  constancy  in  those  due  to  pressure  from  diseased  contiguous  organs. 

"  8.  The  like  is  true  also  of  amblyopia  and  amaurosis,  and  of 
choked  disk  and  optic  neuro-retinitis. 

"  9.  Headache  is  likewise  only  met  with  in  cases  of  pressure  from 
diseased  continuous  organs.  Its  fixed  situation  in  the  posterior  cra- 
nial region  may  in  some  cases  indicate  the  existence  of  a  cerebellar 
disease,  but  it  is  no  more  pathognomonic  of  such  an  affection  than  its 
presence  in  the  frontal  region  would  indicate  a  healthy  cerebellum. 


SYMPTOMATOLOGY   OF   EXCEPHALIC   DISEASES.  357 

"  10.  The  most  diverse  derangements  of  the  motor  and  sensory 
cerebral  and  spinal  nerves  may  exist  in  conjunction  with  cerebellar 
disease,  but  only  in  cases  of  lesions  due  to  pressure.  They  are  not, 
therefore,  in  instances  of  disease  of  the  cerebellum,  of  any  diagnostic 
importance.  On  the  contrary,  they  are  very  apt  to  lead  to  errors  of 
diagnosis.  Still,  however,  if  we  can,  out  of  all  the  symptoms,  select 
some  one  of  derangement  of  motor  or  sensory  nerves,  we  may  find 
important  indications  toward  the  exact  localization  of  the  lesion. 
Thus,  for  instance,  paralysis  of  the  whole  of  the  right  facial  nerve 
indicates  the  existence  of  a  tumor  on  the  corresponding  side,  and  de- 
cided hemiplegia  its  seat  on  the  basilar  surface.  Generally,  how- 
ever, we  must  be  careful  not  to  draw  definite  conclusions  in  this 
respect. 

"11.  Psychical  derangements  are  absent.  Only  under  the  general 
conditions  which  exist  in  all  brain-lesions,  whatever  their  situation, 
are  we  apt  to  meet  with  them  in  affections  of  the  cerebellum.  Never- 
theless, they  are  probably  ordinary  phenomena  in  general  atrophy  of 
the  organ." 

Crura  Cerebelli. 

"  1.  Stationary  destroying  lesions  of  the  crus-cerebelli,  producing 
complete  destruction  of  the  same,  cause  no  characteristic  symptoms  of 
diagnostic  value. 

"2.  Irritative  lesions  alone  produce  such  symptoms,  and  then  only 
when  the  connection  of  the  crus  with  the  cerebellum  is  not  interfered 
with.     Hemorrhages  only  produce  symptoms  in  the  beginning. 

"3.  These  symptoms  consist  in  forced  positions  of  the  trunk,  head, 
and  eyes,  rotatory  motions  on  the  long  axis  of  the  body,  and  in  vertigo, 
with  the  inclination  to  fall  to  one  side. 

"4.  Of  the  foregoing  symptoms,  the  only  ones  which  are  character- 
istic are  the  position  of  the  eyes  and  rotatory  movements  of  the  body 
observed  by  Nonat,  as  all  the  rest,  so  far  as  they  have  been  clinically 
noticed,  have  been  recognized  as  being  due  also  to  other  localized 
lesions. 

"5.  On  the  contrary,  the  turning  of  the  body,  together  with  a 
like  movement  of  the  head  and  eves,  indicates  the  existence  of  a  crus- 
cerebellar  lesion. 

"  (>.  The  direction  of  these  movements  is  sometimes  toward  the 
healthy  side  and  sometimes  toward  the  diseased  side,  but  as  yet  the 
cause  of  these  differences  Is  do!  known. 

"7.  Whether  or  doI  disturbances  of  coordination  and  ataxia  result 
from  lesions  of  the  crus-oerebelli,  is  do!  yet  ascertained. 

"8.  The  foregoing  remarks  refer  entirely  to  the  median  crus  to  the 
pons.  There  is  nothing  to  be  said  relative  to  the  anterior  and  poste- 
rior crura." 


358  DISEASES   OF   THE   BRAIN. 

Pons. 

1.  The  form  of  motor  paralysis  resulting  from  a  lesion  of  one  pyra- 
midal tract  in  the  pons  depends  upon  the  level  at  which  the  lesion  oc- 
curs. In  the  upper  third  of  the  pons  each  pyramidal  tract  contains  all 
the  fibres  which  supply  motor  power  to  the  muscles  on  the  opposite 
side  of  the  body.  Hence  a  lesion  involving  the  motor  tract  in  the 
upper  third  of  the  pons  would  produce  hemiplegia  on  the  opposite  side. 

2.  In  the  middle  third  of  the  pons  the  facial  nerve  decussates  while 
the  motor  fibres  do  not.  A  lesion  below  this  level,  therefore,  would  be 
followed  by  crossed  paralysis — that  is,  by  paralysis  of  the  face  on  the 
same  side  as  the  lesion,  and  paralysis  of  the  arm  and  leg  on  the  oppo- 
site side. 

3.  In  the  lower  third  of  the  pons  the  hypoglossal  nerve  decussates. 
A  lesion  at  this  level  can  be  distinguished  from  a  lesion  of  the  middle 
third  by  the  addition  of  the  symptom  of  paralysis  of  one  side  of  the 
tongue.  The  paralysis  of  the  tongue  would,  of  course,  be  on  the  same 
side  as  the  facial  paralysis.  This  would  cause  a  deviation  of  the 
tongue  toward  the  side  of  the  lesion. 

4.  The  sensory  tract  passes  up  to  the  cerebral  cortex  through  the 
formatio  reticularis.  A  lesion  of  this  region  in  the  upper  third  of  the 
pons  produces  anaesthesia  on  the  opposite  side  of  the  body.  In  the 
middle  third  the  sensory  division  of  the  trigeminus  decussates  ;  hence 
a  lesion  in  the  lower  two  thirds  of  the  pons  results  in  crossed  anaes- 
thesia— that  is,  anaesthesia  of  the  face  on  the  same  side  as  the  lesion, 
and  loss  of  sensibility  in  the  opposite  arm  and  leg. 

5.  The  tract  for  the  transmission  of  muscular  sense  lies  in  the  lem- 
niscus in  the  pons.  A  lesion  involving  the  lemniscus  will  be  fol- 
lowed by  ataxia  of  the  arm  and  leg  on  the  opposite  side  of  the  body. 

6.  The  motor  nuclei  and  nerve  roots  which  may  be  injured  by  lesions 
in  the  pons  are  those  of  the  trigeminus,  the  abducens,  the  facial,  the 
glosso-pharyngeal,  the  pneumogastric,  the  spinal  accessory,  and  the 
hypoglossal.  Irritative  lesions  are  followed  by  spasm  of  the  muscles 
which  these  nuclei  supply,  while  destructive  lesions  result  in  paralysis. 

7.  The  sensory  nuclei  situated  in  the  pons  are  those  of  the  trigemi- 
nus and  the  auditory.  Destruction  of  the  trigeminus,  sensory  nucleus, 
or  its  root  results  in  anaesthesia  of  the  face  on  the  same  side  as  the  lesion. 

8.  Destruction  of  the  ventricular  nucleus  of  the  auditory  nerve 
is  followed  by  deafness  on  the  side  of  the  lesion,  and  disease  of  the 
extra-ventricular  nucleus  produces  rotatory  movements,  or  a  tendency 
to  turn  to  one  side. 

9.  Convulsions  frequently  follow  any  sudden  lesion  in  the  pons. 

Medulla   Oblongata. 

1.  The  diagnosis  of  lesions  of  the  medulla  oblongata  can  not  always 
be  made  with  certainty. 


SYMPTOMATOLOGY   OF   ENCEPHALIC   DISEASES. 


359 


Fig.  30. 


Initrclitay 
Mae/, 


TkeffcA 

Msatkrhm 


2.  Lesions  of  the  formatio  reticularis  in  the  medulla,  as  in  the  pons, 
produce  anaesthesia  of  the  opposite  side  of  the  body  and  of  the  same 
side  of  the  face.  Lesions  of  the  inter-olivary  tract  result  in  a  loss  of 
the  muscular  sense  on  the  opposite  side  of  the  body. 

3.  Lesions  of  one  pyramidal  tract  are  followed  by  paralysis  of  the 
opposite  arm  and  leg,  and,  as  the  nerve  root  of  the  hypoglossal  lies  so 
close  to  the  pyramid,  there  may  also  be  paralysis  of  the  tongue  on 
the   same  side   as 

the  lesion.  The 
face  is  not  para- 
lyzed from  a  lesion 
confined  to  the 
medulla,  as  the 
facial  nerve  and 
nucleus  are  situ- 
ated higher  up  in 
the  anterior  third 
of  the  pons. 

4.  The  nuclei 
and  nerve  roots 
affected  by  lesions 
in  the  medulla  are 
those  of  the  audi- 
tory, glosso-pha- 
ryngeal,  pneumo- 
gastric,  spinal  ac- 
cessory, and  the 
hypoglossal. 

Injury    of    the 
ventricular  nucle- 
us, or  of  its  fibre,  the  stria)  acustica?,  results  in  deafness  on  the  same 
side  as  the  lesion.     Injury  of  the  extra- ventricular  nucleus  gives  rise 
to  rotatory  movements  and  inability  to  retain  an  equilibrium. 

Lesions  of  the  glossopharyngeal  nucleus  and  nerve  are  of  infre- 
quent occurrence,  bul  when  present  produce  loss  of  taste  on  the  same 
side  as  i he  lesion. 

Lesions  of  the  spinal  accessory  and  pneumogastric  nuclei  give  rise 
to  paralysis  of  articulation  and  respiration  on  the  one  hand,  and  to 
huskiness  of  voice,  difficulty  in  breathing,  and  feeble  and  irregular 
heart's  action  on  the  other ;  bu1  these  two  nuclei  are  so  closely  related 
topographically  thai  any  lesion  affecting  one  of  them  usually  affects 

the  ot  her  also. 

Destruction  of  the  hypoglossal  nucleus  or  nerve  gives  rise  to  paral- 
ysis of  the  tongue  on  the  same  side  as  the  lesion.  An  Irritative  lesion, 
however,  causes  spasmodic  fcwitchings. 

."».  Vaso-motor  symptoms,  Buch  as  flushing  of  the  surface  and  sensa* 


J/ctcrTract^- 


S<  <ti  ii  through  the  medi 


fhtly  modified  from  Edinger.) 


360  DISEASES   OF   THE   BRAIN. 

tions  of  heat,  and  of  abnormal  sweating,   are,  according  to  Starr,1 
frequently  observed  following  lesions  of  the  upper  half  of  the  medulla. 

Corpora  Quadrigemina. 

"  1.  The  diagnosis  of  lesions  of  the  corpora  quadrigemina  is  very 
difficult  and  uncertain,  for  the  reason  that  the  symptoms  are  some- 
times exceedingly  ambiguous  and  at  others  scarcely  noticeable. 

"  2.  From  a  consideration  of  the  results  of  our  present  experience, 
it  appears  that  the  symptoms  due  to  lesion  of  the  anterior  and  posterior 
pair  respectively  are  different.  The  implication  of  the  anterior  pair  is 
accompanied  with  diminution  of  the  sense  of  sight,  or  even  blindness. 
This  symptom  is',  however,  of  very  ambiguous  character,  and  must  not 
be  necessarily  referred  to  lesion  of  the  corpora  quadrigemina,  since 
lesions  in  this  region  are  liable  to  affect  the  optic  tract  either  directly  or 
by  pressure.  The  diagnostic  value  of  amaurosis  appears  to  us  as  of  most 
importance  under  the  following  circumstances :  when  it  is  sudden  and 
acute,  with  non-mobility  of  the  pupils,  accompanied  with  other  symp- 
toms of  lesion  of  the  brain  and  with  negative  ophthalmoscopic  results. 

"  3.  Lesions  of  the  posterior  pair  are  accompanied,  but  not  always, 
with  paralysis  or  paresis  of  the  oculo-motor  nerve.  Its  existence  is  not, 
however,  any  more  than  its  absence,  an  infallible  mark  for  diagnosis. 

"  4.  Great  importance  is  to  be  attached  to  the  character  and  ap- 
pearance of  the  oculo-motor  disturbance — a  unilateral  paralysis  may 
exist  from  a  bilateral  lesion,  and,  when  unaccompanied  with  alternate 
paralysis  of  the  extremities,  points  to  the  tubercula  quadrigemina  as 
the  organs  involved. 

"  5.  This  bilateral  implication  of  the  motores  oculorum  appears  to 
be  sometimes  due  to  a  unilateral  lesion  of  the  tubercula  quadrigemina. 

"  6.  Relative  to  the  state  of  the  pupil  nothing  exact  is  known.  It 
appears,  however,  that  lesion  of  the  anterior  pair  arrests  its  reactions. 

"  7.  From  lesions  of  the  posterior  pair  it  appears  that  disturbances 
of  equilibrium  and  coordination  may  result,  similar  to  those  due  to  cere- 
bellar disorders." 

Thalami  Optici. 

"  1.  Relative  to  the  majority  of  the  symptoms  regarded  as  being 
due  to  lesions  of  the  thalamus,  it  is  very  doubtful  if  they  have  a 
direct  relation  to  this  organ,  or  only  occur  indirectly  through  implica- 
tion of  neighboring  cerebral  parts.  Other  manifestations,  really  the 
result  of  thalamic  lesion,  are  of  uncertain  import,  or  they  occur  also 
from  disease  of  other  encephalic  organs. 

"  2.  From  which  it  follows  that  a  certain  diagnosis  of  an  isolated 
thalamic  lesion  is,  in  the  present  state  of  our  knowledge,  in  the  ma- 
jority of  cases  impossible.     Only  under  a  very  favorable  combination 
of  circumstances  is  it  possible  to  arrive  at  a  definite  conclusion. 
1  Starr,  Journ.  New.  and  Merit.  Dis.,  July,  1884. 


SYMPTOMATOLOGY   OF   ENCEPHALIC   DISEASES.  361 

"  3.  Motor  paralysis  cannot,  in  our  opinion,  support  the  idea  of  a 
possible  thalamic  lesion.  On  the  contrary,  when  paralysis  exists  we 
must  suppose  other  parts  to  be  involved,  even  if  the  thalamus  is  the 
principal  seat  of  the  lesion. 

"  4.  The  like  is  true  of  sensory,  paralysis.  If,  through  the  rela- 
tions which  exist  between  injuries  of  the  part  of  the  internal  capsule 
near  the  thalamus,  and  sensibility,  it  is  sometimes  concluded  that  the 
lesion  is  situated  near  the  thalamus  or  in  it  (in  such  a  manner  that  the 
internal  capsule  is  also  implicated),  we  even  then  are  not  warranted  in 
diagnosticating  the  existence  of  a  thalamic  lesion. 

"  5.  That  which  is  said  under  section  4  is  true  also  of  vasomotor 
tracts. 

"  6.  Disturbances  of  sight  may  occur  through  lesion  of  the  poste- 
rior third  of  the  thalamus.  This  is  invariably  homonymous  hemianop- 
sia. But  such  visual  disturbances  do  not  indicate  with  any  degree  of 
sureness  the  existence  of  thalamic  lesions,  as  they  may  occur  with  other 
localized  brain-diseases,  such  as  those  of  the  occipital  lobes,  corpora 
quadrigomina,  and  optic  tracts. 

"7.  A  peculiar  series  of  irritative  motor  disturbances,  such  as  hemi- 
chorea,  athetosis,  and  unilateral  tremor,  are  possibly  due  to  thalamic 
lesion.  Nevertheless,  if  this  fact  were  definitely  established,  these 
phenomena  would,  even  in  undoubted  cases  of  thalamic  disease,  be  of 
little  value  diagnostically,  as  they  may  occur  when  the  lesion  has  a 
very  different  location. 

"  8.  That  a  diminution  or  increase  of  reflex  excitability  indicates 
disease  of  the  thalamus  is  incorrect. 

"  9.  Possibly,  disturbances  of  the  muscular  sense,  and — 

"  10.  Disorders  of  psycho-motor  reflex  actions,  are  indications  of 
thalamic  lesions.  Further  observations  and  investigations  are,  how- 
ever, necessary  on  these  points. 

"Taking  everything  into  consideration,  in  the  present  stale  of  our 
knowledge,  a  lesion  of  the  optic  thalamus  may,  perhaps,  under  a  par- 
ticularly favorable  combination  of  circumstances,  be  diagnosticated, 
if  the  conditions  stated  under  sections  6,  7,  9,  and  10  be  present,  but 
even  then  this  cannot  be  done  with  certainty." 

Corpora  Striata. 

"  1.  Destroying  lesions  of  the  corpus  striatum  may  produce  cross i  d 
motor,  Bensory,  and  vaso -motor  paralyses. 

••  .'.  If  the  lesion  l»e  not  too  small,  motor  hemiplegia  is  uniformly 
present. 

ii ::.  This  hemiplegia  may  gradually  disappear  if  the  lenticular  or 
caudate  nucleus  he  alone  involved.  It  remains,  however,  if  the  inter- 
nal capsule  be  involved,  whether  alone  or  in  conjunction  with  tin-  gray 
nuclei.     In  these  permanent   paralyses—  thai   is  to  say,  those  due  to 


362  DISEASES   OF   THE   BRAIN. 

lesions  of  the  internal  capsule — there  is  often  subsequently  secondary 
muscular  contraction. 

"  4.  Tbe  motor  hemiplegia  resulting  from  stationary  destructive 
lesions  affects  constantly  both  extremities  of  one  side  and  the  inferior 
branch  of  the  facial  nerve.  Usually  the  muscles  of  the  trunk  are  also 
rendered  paretic.  The  hypoglossal  is  either  not  at  all  or  only  in  the 
beginning  affected.     Its  implication  is  seldom  permanent. 

"  In  rare  cases  the  extremities  or  the  facial  are  alone  involved. 

"  5.  The  symptoms  of  lesion  of  the  lenticular  nucleus  are  not  of 
such  a  character  as  to  admit  of  their  distinction  from  those  due  to 
lesion  of  the  caudate  nucleus. 

"  6.  Motor  paralysis  is  the  sole  symptom,  if  the  lesion  is  situated 
only  in  the  anterior  third  of  the  corpus  striatum  in  the  region  sup- 
plied by  the  lenticular  striated  artery. 

"  7.  In  some  cases  hemi-ana3sthesia  is  an  accompaniment  of  the 
hemiplegia.  This  is  characterized  by  the  fact  that  along  with  the 
cutaneous  ana?sthesia  the  nerves  of  special  sense — sight,  hearing,  taste, 
and  smell — on  the  corresponding  side  are  affected ;  still,  these  latter 
are  not  necessary  features  in  hemi-ansesthesia  due  to  lesions  of  the 
corpus  striatum,  as  the  condition  is  generally  confined  to  the  skin. 

"  8.  The  hemi-anresthesia  shows  the  implication  of  the  most  pos- 
terior part  of  the  internal  capsule  with  the  contiguous  part  of  the 
corona  radiata  ;  still,  lesions  may  exist  in  the  posterior  part  of  the 
internal  capsule  between  the  optic  thalamus  and  the  lenticular  nucleus 
without  the  production  of  anaesthesia. 

"  9.  Generally  the  hemiplegia  and  the  hemi-ana?sthesia  exist  to- 
gether. It  is  only  occasionally  that  the  first  disappears  and  that  the 
latter  remains. 

"  10.  Occasionally  disturbances  in  the  functions  of  vaso-motor  in- 
nervation— increased  temperature,  redness,  etc. — occur  in  the  paralyzed 
parts.  These  indicate  the  implication  of  the  posterior  portion  of  the 
internal  capsule. 

"11.  Hemichorea,  hemiathetosis,  and  other  forms  of  hemi-mobile 
spasm  often  occur  in  conjunction  with  lesions  of  the  corpus  striatum. 

Centrum  Ovale. 

In  regard  to  lesions  of  the  white  substance  of  the  brain — constitut- 
ing the  centrum,  no  very  definite  conclusions  are  reached  by  Nothna- 
gel.  Thus  stationary  destroying  lesions  of  occipital,  spheroidal,  and 
anterior  and  middle  frontal  portions,  give  rise  to  no  well-marked 
symptoms.     The  same  is  true  of  pressure-lesions. 

The  most  important  symptom  is  that  resulting  from  lesions  of  the 
anterior  and  posterior  central  regions — motor  paralysis  of  the  opposite 
side,  like  that  caused  by  lesions  of  the  corpus  striatum  or  cortex. 

Aphasia  is  a  probable  symptom  of  lesion  of  the  white  substance  of 
the  foot  of  the  third  frontal  convolution. 


SYMPTOMATOLOGY   OF   ENCEPHALIC   DISEASES.  363 

The  Cortex. 

"  1.  Disease  of  the  surface  of  the  brain — that  is,  of  the  gray  sub- 
stance and  the  immediately  contiguous  white  substance — produces  in 
one  group  of  cases  decided  symptoms ;  in  another  they  are  without 
symptoms,  remaining  latent. 

•■  'I.  Psychical  derangements  indicate,  in  genei-al,  disease  of  the  su- 
perfices  of  the  brain  (Ilirnoberflache),  but  exact  localization  cannot  as 
yet  be  made. 

"3.  Motor  aphasia,  or  the  inability  to  remember  how  to  make  the 
muscular  movements  necessary  for  pronouncing  words,  is  often  due  to 
disease  of  the  cortex  in  the  region  of  the  posterior  extremity  of  the 
inferior  frontal  convolution  ;  but  it  must  be  remembered  that  di- 
of  the  conducting  fibres  from  this  region  also  produce  motor  aphasia. 
Lesions  of  this  part  of  the  cortex  are  also  followed  by  amnesic  aphasia 
— that  is,  by  inability  to  remember  words. 

"4.  Word-blindness,  or  the  loss  of  the  power  of  remembering  the 
appearance  of  written  or  printed  words,  is  due  to  disease  of  the  cortex 
of  the  occipital  lobes  and  perhaps  of  the  angular  gyros. 

"5.  Word-deafness,  or  the  inability  to  remember  the  sound  of 
words,  is  caused  by  a  lesion  of  the  cortex  of  the  anterior  half  of  the 
superior  and  middle  temporal  convolutions. 

"  6.  Paraphasia,  or  the  inability  of  an  individual  to  speak  coherent- 
ly, is,  according  to  Wernicke,  produced  by  lesions  of  the  island  of  Red, 
or  by  a  lesion  of  any  part  of  the  conducting  tract  between  the  cortical 
word  centre  at  the  base  of  the  third  inferior  frontal  convolution  and 
the  word-hearing  centre  in  the  temporal  convolutions. 

u  7.  Hemianopsia  does  not  of  itself  indicate  the  existence  of  a  cor- 
tical lesion.  At  best  we  can  only  suspect  such,  and  then  probably 
in  the  occipital  lobe,  when  the  condition  in  question  is  developed  sud- 
denly, as  a  single  symptom,  and  with  entirely  negative  ophthalmo- 
BCOpical  phenomena — perhaps  after  an  apoplectic  attack. 

"8.  Unilateral  disturbances  of  vision  may  occur  as  the  consequence 

of  lesions  of  the  superficies  of  the  brain.    Hitherto  they  have  only  been 

observed  with  diffused  corl  ical  lesions,  such  as  progressive  paralysis  and 

Icerci.    As  to  their  importance  in  locative  diagnosis,  nothing  of  any 

positiveness  can  be  -aid. 

"9.  Sensory  disturbances  of  the  >*kin  are  sometimes  caused  by 
as  of  the  cortex.  According  to  Dana,  the  Bensory  cortical  centres 
are  hi  the  same  locality  as  the  motor  cortical  centres,  bul  are  more 
diffuse,  and  sensory  symptoms  resulting  from  disease  of  this  area  are 
more  liable  to  b.  transient  than  when  they  are  the  result  ot  lesions 
el-ew  here. 

•(  10.  Unilateral  disturbance  of  the  muscular  sense,  when  it  appears 
by  itself  without  attendant  phenomena,  perhaps  indicates  the  existence 
of  a  lesion  of  the  parietal  lobes,  but  it  must   not  be  forgotten  that  a 


364  DISEASES   OF   THE   BRAIN. 

unilateral  lesion  of  the  lemniscus  in  the  pons  and  medulla  may  produce 
the  same  symptom. 

"  11.  Motor  derangements  occur  in  conjunction  with  cortical  lesions, 
ami  under  certain  circumstances  may  by  tbeir  character  enlighten  us  in 
regard  to  the  latter. 

"  12.  Sometimes  the  paralysis  appears  as  a  simple  hemiplegia,  such 
as  is  ordinarily  the  result  of  a  lesion  of  the  motor  division  of  the  in- 
ternal capsule,  with  or  without  secondary  contractions  in  the  paralyzed 
extremities.  In  this  case  the  diagnosis  is  impossible.  Nevertheless, 
the  belief  that  a  cortical  lesion  existed  would  be  strengthened  if  there 
were  also  permanent  aphasia. 

"  If,  in  connection  with  paralysis  of  the  extremities  and  the  facial 
and  the  hypoglossal  nerves,  there  is  ptosis,  it  is  probable  that  a  corti- 
cal lesion  exists. 

"  On  the  contrary,  decided  disturbances  of  sensibility  occurring  in 
conjunction  wTith  motor  hemiplegia  indicate  either  that  the  lesion  is 
not  cortical,  or  that,  if  it  is,  it  involves  the  cortex  to  a  wide  extent. 

"  13.  Relatively,  paralyses  due  to  lesions  of  the  cortex  are  often 
monoplegias,  partial  hemiplegias,  isolated  paralyses  of  the  facial,  the 
hypoglossal,  and  the  nerves  of  the  arm  (rarely  of  the  leg),  or  of  the 
arm  and  leg,  or  arm  and  face. 

"  14.  These  monoplegias,  their  intracerebral  origin  being  first  de- 
termined, indicate,  not  with  absolute  certainty  but  with  great  proba- 
bility, a  cortical  lesion. 

"  15.  The  character  and  development  of  these  monoplegias  alone 
are  of  no  consequence  as  indicating  a  cortical  lesion. 

"  16.  On  the  other  hand,  certain  kinds  of  motor  irritative  phenom- 
ena are  of  great  value  in  the  diagnosis  of  cortical  lesions. 

"  17.  These  appear  sometimes  as  partial  convulsions  of  individual 
muscles,  and  occur  either  as  the  consequences  of  haemorrhage  or  soften- 
ing, or  by  the  development  of  a  tumor,  and  which  subsequently  are  fol- 
lowed by  paralysis  of  the  affected  muscles.  In  such  cases  we  may  with 
great  probability,  almost  with  certainty,  suspect  a  lesion  of  the  cortex. 

"  Or  partial  clonic  convulsions  make  their  appearance  in  the  already 
paralyzed  region.  In  such  cases,  judging  by  our  present  experience, 
a  lesion  of  the  cortex  exists. 

"  18.  In  other  cases  the  motor  phenomena  are  those  of  a  general 
epileptif orm  attack,  and  with  the  peculiarity  that  the  typical  recurring 
spasm  always  begins  in  the  same  group  of  muscles  in  an  extremity  or 
half  of  the  face.  This  form  of  convulsion  is  always  developed  after 
an  existent  paralysis.  It  may  be  regarded  as  a  probable  symptom  of 
lesion  of  the  cortex. 

"  19.  The  existence  of  motor  symptoms  from  lesion  of  the  cortex 
indicates  that  the  seat  of  the  morbid  cause  is  in  the  anterior  central 
and  posterior*  central  convolutions  and  the  paracentral  lobule." 


SECTION  II. 
DISEASES  OF  THE  SPIRAL  CORP . 


CHAPTER  I. 

SPIRAL    CONGESTION. 


Thotjgh  congestion  of  the  spinal  cord,  like  that  of  the  brain,  is  of 
two  kinds,  active  and  passive,  yet  the  symptoms  and  general  course  of 
the  two  varieties  are  so  generally  alike,  that  nothing  would  be  gained 
by  considering  them  separately. 

Symptoms. — The  symptoms  of  spinal  congestion  are  referable  to  the 
cord  and  to  those  parts  of  the  body  below  the  seat  of  the  lesion.  The 
most  prominent  local  phenomenon  is  pain,  which  is  rarely  acute,  but  is 
described  as  a  dull,  aching  sensation  similar  to  that  experienced  in  the 
back  after  severe  and  long-continued  muscular  exertion  in  a  stooping 
attitude.  This  pain  is  increased  by  the  recumbent  posture  and  by  stand- 
ing, if  the  lower  part  of  the  cord  be  its  seat ;  but  pressure,  if  steadily 
applied,  does  not  augment  it.  A  sudden  blow  or  a  shock,  such  as  that 
produced  by  making  a  false  step,  aggravates  it  to  a  considerable  ex- 
tent. 

A  sensation  of  heat  is  occasionally  experienced  in  the  cord,  which  is 
not  unpleasant,  and  which  is  not  affected  by  pressure. 

With  the  local  symptoms  there  are  others  still  more  notable  per- 
ceived in  the  parts  of  the  body  below  the  seat  of  the  disease.  Thus,  if 
as  is  very  generally  the  case,  the  lesion  be  situated  in  the  dorsal  or  lum- 
bar region,  there  are  disturbances  of  sensibility  and  motility  in  the 
lower  extremities.  The  various  sensations  indicating  anesthesia,  are 
present,  and  are  usually  fust  experienced  in  tin'  skin  covering  the  under 
surface  <>f  the  toes.  Formication,  "pins  and  needles,"  tingling,  and  a 
feeling  as  if  the  toes  are  swollen,  are  noticed.  It  is  rarely  the  case 
that  the  anaesthesia  is  complete.  Its  extent  and  exact  situation  may 
be  accurately  determined  by  the  eesthesiometer. 


3C6  DISEASES   OF   THE   SPINAL   CORD. 

Sometimes  there  is  hyperesthesia,  and  occasionally  both  conditions 
coexist.  The  extent  of  either  may  be  definitely  measured  with  the 
festhesiometer.  Shooting  pains  in  the  limbs  and  along  the  course  of 
the  nerves  coming  from  the  diseased  part  of  the  cord  are  now  and  then 
present,  but  they  are  not  a  prominent  feature  in  simple  congestion. 

A  sensation  of  constriction  is  at  times  complained  of,  and  is  referred 
to  the  body  or  one  or  both  of  the  limbs.  It  is  compared  to  the  feeling 
which  would  be  produced  by  a  tight  cord,  or  encasement  in  an  unyield- 
ing garment.  It  is  rare  in  uncomplicated  spinal  congestion.  Accord- 
ing to  the  situation  of  the  lesion,  there  are  pains  either  in  the  abdomen, 
chest,  or  both,  and  there  may  be  dyspnoea  and  palpitation  of  the  heart. 
In  three  cases  under  my  care,  the  difficulty  of  breathing  and  irregula-r 
cardiac  action  were  prominent  features.  Similar  cases  are  cited  by 
Ollivier  x  (d' Angers).  The  temperature  of  the  parts  of  the  body  below 
the  lesion  is  always  reduced,  from  the  fact  that  the  vaso-motor  nerves 
are  involved. 

Erections  of  the  penis  are  common,  especially  after  the  patient  has 
been  in  the  recumbent  position  for  some  time. 

The  most  striking  phenomena  of  spinal  congestion  are  those  con- 
nected with  the  alterations  of  motility.  Paraplegia  is  always  present 
to  some  extent,  though  it  is  rarely  complete.  Thus  the  patient,  though 
unable  to  walk,  can  generally  move  the  legs  when  sitting  down  or  lying 
in  bed.  Twitchings  of  the  muscles  are  occasionally  present,  but  not 
often  to  a  severe  degree. 

The  loss  in  the  power  of  motion,  like  the  alterations  in  sensibility, 
is  only  present  in  those  parts  of  the  body  situated  below  the  diseased 
parts  of  the  cord.  The  bladder  is  very  generally  affected,  either  in  its 
own  muscular  tissue  or  in  its  sphincter.  In  the  first  case,  there  is  a  dif- 
ficulty of  expelling  the  urine,  owing  to  loss  of  expulsive  power,  and  this 
is  aggravated  by  paralysis  of  the  abdominal  muscles,  or  there  is  incon- 
tinence of  urine  from  paralysis  of  the  sphincter.  Both  conditions  may 
coexist,  and  then,  when  a  sufficient  quantity  of  urine  has  accumulated  in 
the  bladder,  it  dribbles  away.  In  such  a  condition,  the  bladder  is  never 
entirely  empty,  and  the  urine  is  passed  alkaline  and  fetid. 

The  sphincter  of  the  rectum  is  sometimes  involved,  producing  in- 
voluntary evacuation  of  the  fasces,  but  obstinate  constipation  from 
paralysis  of  the  abdominal  muscles,  and  consequent  loss  of  expulsive 
power,  are  much  more  common.  Reflex  excitability  is,  according  to 
my  experience,  invariably  lessened,  and  is  sometimes  entirely  abolished. 

The  electro-muscular  contractility  of  the  paralyzed  muscles  is  always 
more  or  less  diminished,  though  not  to  the  same  extent  as  in  some 
other  affections  of  the  cord.  As  a  general  rule,  the  farther  the  muscle 
is  from  the  centre  the  less  is  its  electro-muscular  contractility. 

1  "  Trait6  des  maladies  de  la  raocl'e  dpiniere,"  troisieme  Edition,  Paris,  1837,  tome 
iii.,  pp.  1-137. 


SPINAL   CONGESTION.  367 

The  tendency  of  spinal  congestion  is  to  extend  itself  and  eventually 
to  involve  the  whole  cord.  In  the  active  form  of  the  disease,  this  pro- 
cess often  takes  place  with  great  rapidity,  and  the  symptoms  generally 
are  more  pronounced  and  succeed  each  other  with  more  promptness. 
The  phenomena  of  spinal  congestion  are  always  rendered  more  decided 
by  the  patient's  assuming  the  recumbent  posture.  He  is  hence  more 
paralyzed  in  the  morning  before  rising  from  bed  than  in  the  evening 
before  he  retires.  This  is  due  to  the  fact  that  the  position  in  question, 
especially  if  he  lies  on  his  back,  allows  the  spinal  blood-vessels  to  be- 
come more  readily  distended.  It  is  the  same  thing  as  regards  the  cord, 
that  keeping  the  head  in  a  dependent  position  would  be  as  regards  the 
brain. 

Bed-sores  are  not  common.  Radcliffe  l  seems  to  assert  that  they 
are  never  met  with.  Brown-Sequard 2  says  an  ulceration  upon  the 
sacrum  or  nates  is  not  rare  in  this  affection.  Ollivier  s  does  not  men- 
tion them  in  his  account  of  the  disease.  Of  the  large  number  of  cases 
of  spinal  congestion  that  have  come  under  my  observation,  bed-sores 
occurred  in  but  two,  and  in  these  there  was  reason  to  believe  they  were 
not  the  special  result  of  the  lesion  of  the  cord. 

According  as  the  antero-lateral  or  posterior  columns  are  mainly 
affected,  the  symptoms  of  spinal  congestion  differ.  Thus,  in  the  former 
case,  the  phenomena  are  chiefly  manifested  as  regards  motility,  in  the 
latter  as  regards  sensibility.  Generally  both  sets  of  columns  are  in- 
volved. In  spinal  amentia,  as  wo  shall  presently  see,  this  is  not  the 
case. 

Causes. — The  most  common  cause  of  spinal  congestion,  according  to 
ray  experience,  is  exposure  to  intense  cold.  Fevers  appear  to  be  next 
in  frequency,  especially  those  of  malarious  origin,  and  the  excessive 
use  of  alcoholic  liquors  probably  comes  next  as  a  causative  influence. 

Venereal  excesses,  and  maintaining  the  erect  posture  for  a  long  time, 
were  the  obvious  cause  in  several  cases.  This  last  influence  was  very 
well  marked  in  the  case  of  an  eminent  lawyer  of  this  city,  who  became 
suddenly  affected  with  spinal  congestion  after  making  a  speech  of  s<  v- 
eral  hours'  duration.  The  suppression  of  a  customary  discharge,  such 
as  the  menstrual  flow  or  a  hemorrhoidal  bleeding,  is  likewise  liable  to 
induce  congestion  of  the  cord.  I  have  recently  treated  two  cases,  in 
which  the  congestion  of  the  cord  followed  the  cold  stage  of  intermittent 
fever  ;  mid  it  is  occasionally  the  result  of  blows  and  falls.  I  have  scon 
several  oases  which  were  due  to  railway  injuries. 

In  one  of  these  the  patient,  an  elderly  gentleman,  was  violently 
thrown  to  the  floor  of  a  railway-car  in  consequence  of  a  oollision  with  a 
stationary  train  in  front.     At  first,  there  were  nausea,  vomiting,  slow 

1  Lectures  on  the  "  I'i  ignosia  and  Treatment  of  the  Principal  Forms  of  i'arilysis  of  the 
Lower  Extremities,"  Philadelphia,  L861,  p.  89. 

*  Op.  cit.       3  Reynolds'!  "Syst<  m  ol  Medicine,"  rol  ii.,  p.  622. 


368  DISEASES   OF   THE   SPIXAL   CORD. 

and  feeble  pulse,  and  very  great  nervous  prostration — in  fact,  all  the 
more  prominent  symptoms  of  shock.  The  injured  man  revived  after 
the  administration  of  stimulants,  and  was  partly  enabled  to  walk  to  an 
hotel  near  by.  On  the  following  day,  however,  pain  was  experienced 
in  the  lower  dorsal  region,  and  difficulty  was  experienced  in  moving 
the  legs.  Sensibility  was  impaired  in  the  lower  extremities.  The 
bladder  was  partially  paralyzed,  and  in  consequence  the  urine  was 
drawn  off  with  the  catheter.  From  this  time  his  condition  became 
worse,  till  at  last,  sensibility  was  entirely  abolished  in  both  lower 
extremities,  and  the  power  of  motion  was  altogether  lost.  The  bladder 
never  became  entirely  paralyzed.  The  sphincters  both  of  the  bladder 
and  rectum  remained  unaffected.  "When  I  saw  him,  three  months  after 
the  reception  of  the  injury,  he  was  incapable  of  feeling  the  prick  of  a 
pin  in  any  part  of  his  body  below  the  first  lumbar  vertebra,  and  could 
not  move  a  single  muscle  of  the  lower  extremities.  There  were  no  bed- 
sores, and  the  condition  of  the  limbs  was  not  impaired.  Electro- 
muscular  contractility,  though  greatly  lessened,  was  not  completely 
lost.  A  two-cell  galvano-faradic  battery,  when  used  with  its  full  power, 
failed  to  produce  any  contraction;  but  all  the  muscles  responded  fee- 
bly to  the  interrupted  primary  current  from  a  hundred-cell  battery. 
Reflex  excitability  was  entirely  lost.  There  were  no  twitchings  or  spas- 
modic contractions  of  the  paralyzed  muscles.  Nor  had  any  such  move- 
ments ever  been  noticed.  Under  the  use  of  ergot,  iodide  of  potassium, 
and  the  primary  galvanic  current  to  the  spine  and  the  muscles  of  the 
lower  extremities,  he  recovered  so  far  as  to  be  able  to  walk  short  dis- 
tances with  crutches,  and  obtained  full  control  of  his  bladder,  but  there 
was  no  marked  improvement  in  the  sensibility. 

In  another  case,  the  affection  was  apparently  induced  by  excessive 
muscular  exertion.  The  patient  went  to  bed,  feeling  fatigued,  and  in 
the  morning  was  entirely  paraplegic.  The  paralysis  gradually  extended 
upward,  till  on  the  third  day  both  arms  were  devoid  of  power.  On  the 
fifth  day  I  saw  him.  He  was  then  deprived  of  voluntary  power  in  both 
upper  and  lower  extremities.  Reflex  excitability  was  notably  impaired, 
as  was  also  the  electric  contractility  of  the  muscles.  He,  however,  had 
full  power  of  the  bladder  and  sphincters.  On  the  sixth  day  the  left 
side  of  his  face  became  paralyzed.  He  was  treated  as  the  case  just 
described,  and  recovered  entirely  in  the  course  of  about  two  months. 
He  has  remained  perfectly  well  ever  since,  and  able  to  attend  to  his 
business  as  a  commercial  traveler. 

Leudet  *  reports  several  cases  in  which  symptoms  similar  to  those 
present  in  the  foregoing  examples  were  produced  by  falls  and  excessive 
muscular  exertion,  and  which  were,  in  his  opinion,  instances  of  spinal 

1  '•  Sur  la  congestion  de  la  moelle  survenant  a  la  suite  de  chutes  et  d'efforts  violenta," 
Archives  generates,  I860,  tome  i.,  p.  257. 


SPINAL   CONGESTION.  369 

congestion.  In  a  subsequent  paper '  he  returns  to  the  subject  and 
adduces  additional  cases  in  support  of  his  view.  In  his  opinion  the 
congestion,  with  its  accompanying  symptoms,  is  produced  at  the  end 
of  a  period  often  of  some  hours  after  the  operation  of  the  exciting 
cause.  Sometimes  the  congestion  is  limited,  affecting  only  a  segment 
of  the  spinal  cord  ;  at  others  it,  from  the  very  first,  involves  the  cord 
throughout  its  entire  length.  This  fact  explains  the  circumstance  that 
the  symptoms  are  by  no  means  uniform,  either  as  regards  their  char- 
acter or  location. 

Among  the  effects  of  working  under  compressed  air,  spinal  conges- 
tion must  be  included.  Drs.  Babington  and  Cuthbert,2  of  Dublin,  have 
called  attention  to  this  fact;  and  Dr.  Clark,3  of  St.  Louis,  has  recently 
brought  forward  several  additional  cases  occurring  in  the  workmen  in 
the  caisson  used  in  building  the  bridge  over  the  Mississippi  River. 

Passive  spinal  congestion  may  be  caused  by  any  obstruction  to  the 
return  of  blood  by  the  veins,  such  as  cirrhosis  of  the  liver,  pregnancy, 
abdominal  tumors  of  various  kinds,  diseases  of  the  lungs  or  right  side 
of  the  heart,  and  the  long-continued  maintenance  of  the  dorsal  decu- 
bitus. 

Diagnosis. — Spinal  congestion  is  liable  to  be  confounded  with  several 
other  affections,  and  with  some  to  the  great  injury  of  the  patient.  Thus 
it  may  not  be  distinguished  from  spinal  anremia,  a  condition  likewise 
giving  rise  to  paraplegia,  but  of  which  the  treatment  is  very  different. 

It  may  be  diagnosticated  from  anaemia  of  the  posterior  columns 
by  the  facts  that  in  it  there  is  pain  in  the  cord,  increased  by  pressure 
on  the  spinous  processes  of  the  vertebra?,  or,  if  there  is  no  spontaneous 
pain,  such  pressure  causes  it ;  by  the  disturbance  induced  in  the  cranial, 
thoracic,  or  abdominal  viscera,  according  to  the  part  of  the  cord  af- 
fected being  much  more  prominent;  by  the  circumstance  that  women 
are  more  generally  its  subjects;  and  that,  when  there  is  paralysis,  it  is 
hysterical  and  transitory  in  character.  In  anaemia  of  the  antero-lateral 
columns  there  is  often  a  previous  affection  generally  of  the  urinary 
organs  which  has  caused  the  amemia,  or  some  other  source  of  reflex 
irritation  or  exhaustion  can  be  discovered.  Besides,  in  spinal  anaemia, 
either  of  the  posterior  or  antero-lateral  columns,  the  symptoms  are  less 
strongly  marked  after  the  patient  has  been  lying  down  some  time, 
is  the  reverse  is  the  case  in  congestion. 

Spinal  anaemia  never  produces  any  urinary  derangement,  although 
such  trouble  may  cause  spinal  anannia.  In  a  case,  therefore,  in  winch 
there  was  doubt  as  to  the  spinal  cord  being  in  a  state  of  congestion  or 

•  '"Beoherchea  cliniquea  but  la  congestion  <Je  la  moeQe  a  la  suite  de  chutes  ou 
d'elTorts,"  Clini  [U  le  PH6tel-Dieu  de  Rouen,  Paris,  1>TI. 

*'T.  ansed  l»y  working  under  Compressed  Air,"  Dublin  Quarterly  Journal 

*  St.  Louis  M(dioal  ami  Suryicd  Journal. 


370  DISEASES  OF  THE  SPINAL  CORD. 

anaemia,  the  order  of  sequence,  as  regards  the  paraplegia  and  bladder- 
difficulty,  would  seem  to  render  the  diagnosis  exact.  In  spinal  anaemia 
the  bladder  is  affected  before  the  paraplegia  appears  ;  in  spinal  conges- 
tion the  paraplegia  comes  on  before  the  bladder  is  involved. 

In  spinal  anaemia  there  is  no  formication,  pricking,  tingling,  or  other 
sensation  indicative  of  anassthesia.  Hyperaesthesia  is,  on  the  contrary, 
exceedingly  common. 

The  further  diagnostic  marks  will  be  considered  when  we  come  to 
the  subject  of  spinal  anaemia. 

Congestion  is  distinguished  from  inflammation  of  the  cord  by  the 
facts  that  in  it  the  jerkings  of  the  limbs  are  slight,  that  the  paralysis  is 
not  so  extreme,  that  the  urine  is  never  alkaline,  unless  there  is  paralysis 
of  the  bladder,  that  the  pain  in  the  cord  is  less,  and  by  the  infrequency 
of  the  feeling  of  constriction  at  the  upper  limit  of  the  lesion. 

From  meningitis  it  is  diagnosticated  by  the  absence  of  spasms  in 
the  muscles  of  the  back,  and  by  the  fact  that  movements  of  the  para- 
lyzed limbs  do  not  cause  pain. 

Prognosis.: — In  simple  uncomplicated  spinal  congestion  the  progno- 
sis is  not  unfavorable,  if,  in  addition,  the  case  be  put  under  suitable 
treatment  at  an  early  period.  It  must  be  remembered,  however,  that 
there  is  a  tendency  to  interstitial  changes,  and  that,  if  the  vessels  of 
the  cord  be  left  for  a  long  time  in  a  state  of  turgidity,  it  may  be  im- 
possible to  prevent  structural  alterations  of  greater  severity.  In  some 
cases,  especially  those  of  traumatic  cause,  the  symptoms  are  quite  eva- 
nescent, disappearing  in  the  course  of  a  few  hours.  It  is  better,  there- 
fore, for  the  physician  to  be  guarded  in  expressing  his  prognosis  in 
such  instances  when  recent,  till  sufficient  time  has  elapsed  for  the  ten- 
dency of  the  morbid  process  to  be  manifested. 

Morbid  Anatomy. — The  post-mortem  appearances  in  cases  of  con- 
gestion of  the  spinal  cord  are  either  in  the  cord  proper  or  its  mem- 
branes. As  regards  the  first,  section  shows  increased  vascularity  both 
of  the  gray  and  the  white  substance,  especially  if  microscopical  exam- 
ination be  made.  The  capillaries  will  be  found  increased  in  size  and 
more  numerous  than  in  the  normal  condition. 

The  membranes  of  the  cord  contain  very  large  and  very  tortuous 
vessels,  and  in  congestion  they  are  rendered  still  larger  and  more  com- 
plex in  their  anastomoses.  The  pressure  which  they  are  capable  of 
exerting  upon  the  cord  is  not  inconsiderable. 

It  is  almost  invariably  found  that  the  cerebro-spinal  fluid  is  in- 
creased in  quantity. 

These  evidences  of  congestion  are  sometimes  extremely  limited  in 
their  extent,  at  others  the  whole  length  of  the  cord  is  involved. 

Pathology. — The  symptoms  which  result  from  congestion  of  the 
cord  are  of  two  distinct  classes:  increased  excitability  from  hyperaemia, 
and  interruption  of  the  proper  functions  of  the  cord  from  pressure. 


SPINAL  CONGESTION.  371 

The  former,  in  the  main,  results  from  the  increased  amount  of  blood 
in  the  gray  matter  and  white  substance ;  the  latter  from  the  enlarged 
meningeal  vessels  and  the  increased  amount  of  cerebro-spinal  fluid, 
which,  in  the  form  of  serous  effusion,  is  the  result  of  their  turgidity. 
As  one  or  the  other  of  these  conditions  predominates,  we  have  some 
symptoms  more  prominent  than  others.  Thus  hyperesthesia  indicates 
rather  hyperemia  of  the  gray  substance,  anaesthesia  pressure  upon  the 
white  substance.  Twitchings,  when  present,  are  likewise  the  result  of 
over-excitation  of  the  motor  tract  ;  while  motor  paralysis  is  induced 
by  pressure  upon  the  anterolateral  columns. 

The  modifications  which  may  be  produced  in  the  intensity  of  the 
symptoms  by  the  position  of  the  body  show  the  effect  of  pressure  very 
clearly.  In  the  recumbent  posture  on  the  back,  the  blood  gravitates  in 
large  amount  to  the  spinal  vessels,  pressure  on  the  cord  is  increased, 
and  the  phenomena  of  anaesthesia  and  paralysis  are  more  strongly 
marked.  Again,  causes  which  increase  the  activity  of  the  circulation, 
such  as  alcoholic  stimulants,  and  others  which  directly  augment  the 
amount  of  blood  in  the  cord,  such  as  strychnia  and  phosphorus,  invari- 
ably increase  the  hyperesthesia  and  induce  muscular  twitchings,  even 
if  they  have  not  previously  been  observed. 

Treatment. — In  cases  of  spinal  congestion  which  come  on  suddenly, 
and  which  are  therefore  acute  in  their  character,  such  as  result  from  the 
sudden  arrest  of  an  habitual  discharge,  sudden  and  violent  muscular 
exertion,  or  falls,  blood  may  be  drawn  locally  from  the  spinal  region  by 
cups  or  leeches.  The  best  place  for  the  application  of  the  latter  is  the 
verge  of  the  anus,  and  I  have  several  times  witnessed  very  decidedly 
satisfactory  results  from  their  use  in  this  situation. 

Purgatives  are  likewise  beneficial,  and  preference  should  be  given 
to  those  which  produce  watery  evacuations,  as  thereby  the  overloaded 
vessels  are  relieved,  and  the  absorption  of  the  superabundant  cerebro- 
spinal fluid  facilitated.  Nothing  can  be  better  for  this  purpose  than 
the  sulphate  of  magnesia  given  in  doses  of  a  drachm  two  or  three  times 
a  day. 

In  this  form  the  ergot  of  ry<'  may  be  given  with  advantage  from  the 
very  inception  of  the  disorder.  In  the  more  chronic  form  it  is  indis- 
pensable. It  should  be  administered  in  very  much  larger  doses  than  are 
laid  down  in  the  text-books  on  materia  medica.  I  am  in  the  habit  of 
Qging  it  in  this  and  analogous  spinal  diseases,  in  doses  of  a  drachm  of  the 
fluid  extract  three  times  a  day.  The  action  of  the  ergot  is  to  lessen  the 
diameter  of  the  blood- vessels  of  the  oord  by  its  oonstringing  power  over 
the  organic  muscular  fibre  entering  into  the  composition  of  their  walls. 
Ten  years  ago1  I  spoke  as  follows:  "But  I  bave  recently  ascertained 

1  "A  Clinical  Lecture  on  Ohronlo  Myelitis,  delivered  In  the  Baltimore  infirmary," 
March  10,  1081,  American  Mtdioal  Tim>»,  .June  15,  1801,  r>.  379. 


372  DISEASES   OF   THE   SPINAL   CORD. 

by  actual  experiment  that  ergot  does  not  exert  the  influence  in  ques- 
tion. I  prepared  a  weak  aqueous  infusion  of  this  substance  and  placed 
it  on  the  web  of  a  frog's  foot  under  the  microscope.  In  a  few  moments 
contraction  of  the  capillaries  ensued,  and  they  became  so  small  as  not 
to  allow  of  the  passage  of  the  blood-corpuscles.  This  experiment  I 
have  repeated  several  times,  and  am  perfectly  satisfied  that  the  result 
is  as  I  have  stated.  More,  I  have  frequently  injected  small  quantities 
of  the  infusion  into  the  stomach  of  trogs,  and  contraction  of  the  capil- 
laries of  the  web  always  followed." 

These  experiments,  therefore,  fully  confirmed  those  made  a  short 
time  previously  by  Dr.  Brown-Sequard. 

Since  that  time  I  have  given  it  in  a  large  number  of  cases  of  dis- 
eases of  the  spinal  cord,  congestion  among  them,  in  which  it  was  neces 
sary  to  diminish  the  amount  of  blood  in  the  spinal  vessels,  and  I  am 
entirely  satisfied  that  such  is  its  effect  ;  but  I  never  obtained  its  full 
influence  till,  in  accordance  with  the  suggestion  of  Dr.  A.  Jacobi,  of 
this  city,  I  adopted  the  practice  of  giving  it  in  what  may  be  called  very 
large  doses.  Among  the  cases  which  first  came  under  my  care,  since 
my  residence  in  New  York,  was  that  of  Mr.  W.,  of  Tennessee,  who  had 
become  affected  with  congestion  of  the  cord,  from  exposure  to  cold  and 
dampness.  When  I  first  saw  him  he  was  unable  to  walk  without  the 
assistance  of  crutches,  and  a  man  on  each  side  of  him  holding  his 
shoulder.  He  had  paralysis  of  the  bladder,  which  had  come  on  after 
the  paraplegia,  and  a  constant,  dull,  aching  pain  in  the  loins.  There 
were  also  occasional  startings  of  the  legs,  especialhy  after  he  had  gone 
to  bed.  All  his  symptoms  were  worse  in  the  morning.  I  at  first  gave 
him  ten  drops  of  the  fluid  extract  of  ergot  three  times  a  day,  but,  con- 
tinuing this  for  two  weeks  without  effect,  I  at  once  increased  the  doses 
to  a  teaspoonful.  In  less  than  a  week  the  effects  were  manifest.  Sen- 
sibility began  to  return  in  the  extremities,  the  strength  increased,  the 
bladder  began  to  contract  on  its  contents,  the  lumbar  pains  ceased,  and 
by  the  end  of  a  month  he  had  entirely  recovered.  A  few  weeks  after- 
ward he  had  a  relapse,  but  the  ergot,  taken  as  before  for  ten  days,  again 
restored  him,  and  he  has  since  remained  perfectly  well. 

In  the  case  of  Mr.  T.,  of  Norfolk,  Virginia,  whose  affection  was 
apparently  the  result  of  exposure  to  cold  and  dampness,  and  who  wa 
barely  able  to  walk  with  two  canes,  a  complete  cure  was  accomplished 
by  the  use  of  ergot  continued  for  about  a  month.  In  two  other  cases 
occurring  in  mechanics  of  this  city,  ergot  was  the  only  remedy  em- 
ployed, and  both  were  entirely  cured  in  less  than  a  month. 

In  several  cases  I  have  administered  the  ergot  hypodermically  in 
doses  of  five  grains  daily  of  Beaujon's  extract,  but  I  am  convinced  that 
nothing  is  gained  by  this  course.  As  regards  the  efficacy  of  ergot  in 
spinal  congestion,  there  is  not,  in  my  opinion,  any  doubt.  Even 
when  it  fails  to  effect  a  cure,  its  good  influence   is  at  least  shown 


SPINAL  ANAEMIA.  373 

for  a  time.  I  would  as  soon  think  of  treating  intermittent  fever  with- 
out quinine  as  congestion  of  the  spinal  cord  without  ergot. 

Belladonna  is  also  a  valuable  remedy  in  spinal  congestion,  especially 
when  there  is  paralysis  of  the  sphincter,  or  when  the  pain  in  the  back 
is  severe.  The  tincture,  in  doses  of  fifteen  drops  three  times  a  day, 
may  be  employed,  and  a  belladonna  plaster  may  be  applied  to  the  pain- 
ful region  of  the  spine. 

The  hot  douche — the  water  being  of  the  temperature  of  98°  Fahr. — 
to  the  spinal  column  is  an  excellent  means  of  determining  the  blood 
from  the  deep  to  the  superficial  vessels.  The  water  should  be  allowed 
to  fall  from  the  height  of  about  two  feet  upon  the  naked  back  over  the 
diseased  part  of  the  cord  every  day  for  about  five  minutes.  Dry  cups 
are  also  valuable  adjuncts. 

Electricity  is  always  useful.  The  constant  current  should  be  applied 
to  the  spine  over  the  affected  part  of  the  cord,  and  the  intensity  and 
quantity  should  be  as  great  as  the  patient  can  endure  without  much 
discomfort.  I  am  not  sure  that  it  makes  any  difference  in  which  direc- 
tion the  current  be  passed.  Of  its  benefit  I  have  no  doubt.  The  dura- 
tion of  the  application  should  not  exceed  ten  minutes.  The  beneficial 
effect  is  probably  due  to  the  diminution  of  the  calibre  of  the  blood- 
vessels through  its  action  on  the  vaso-motor  nerves. 

The  induced  current  should  be  used  to  the  paralyzed  muscles,  so  as 
to  excite  them  to  contract.  In  this  way  their  nutrition  is  promoted, 
and  any  tendency  to  atrophy  from  disuse  obviated. 

The  primary  current  should  not  be  employed  more  frequently  than 
every  alternate  day.  The  induced  may  be  used  every  day  for  half  an 
hour  or  longer,  short  of  causing  fatigue. 

I  will  only  add  that  strychnia  and  phosphorus  should  never  be  ad- 
ministered in  congestion  of  the  cord,  as  their  action  is  the  very  reverse 
of  that  desired,  and  irreparable  damage  may  be  done  by  their  use. 


CHAPTER   II. 


SPIRAL  ANAEMIA.— AKJEMI A   OF   THE  POSTERIOR    COLUMNS.— AMSMIA   OF   THE 
A  yTFit  0-  LA  TERA  L  COL  UM 

A  deficient  quantity  of  blood  in  the  spinal  cord,  or  a  depravation 
in  the  quality  of  the  blood  circulating  through  its  tissue,  gives  rise  to 
two  cognate,  but,  so  far  as  their  phenomena  go,  differenl  affections.  In 
one  of  these,  which  has  hitherto  been  known  as  spinal  irritation,  the 
morbid  action  is  in  a  greal  measure  confined  to  the  posterior  columns 
of  the  cord  ;  in  tlio  other,  which  embraces  several  differeatiy-named 
disorders,  characterized  by  paralysis,  such  as  reflex  paralysis,  inhibitory 


374  DISEASES  OF  THE  SPINAL  CORD. 

paralysis,  spinal  paresis,  paralysis  from  peripheral  irritation,  etc.,  the 
anterolateral  columns  are  mainly  affected. 

In  thus  specifically  locating  the  lesions  in  these  affections,  I  am 
aware  of  the  fact  that  post-mortem  examinations  are  wanting  to  sup- 
port them.  Nevertheless,  the  symptoms  characteristic  of  each  are  so 
distinctly  marked,  and  are  in  such  intimate  physiological  relation  with 
the  regions  of  the  cord  specified,  that  I  do  not  think  I  am  at  all  exceed- 
ing the  limits  of  probability. 

Retaining  the  name  of  spinal  irritation,  as  one  well  known  to  the 
profession,  it  will  nevertheless  be  understood  that,  in  my  opinion,  the 
proper  designation  of  the  disease  would  be  anaemia  of  the  posterior  col- 
umns of  the  spinal  cord.  I  have  arrived  at  this  view  after  a  very  care- 
ful consideration  and  analysis  of  the  symptoms  observed  in  a  large  num- 
ber of  cases. 

The  same  remarks  are  applicable,  mutatis  mutandis,  to  reflex  para- 
plegia, a  symptom  which  I  am  very  sure  results  from  anaemia  of  the 
antero-lateral  columns  of  the  cord. 


ANAEMIA   OF    THE    POSTERIOR    COLUMNS    OF    THE    SPINAL   CORD. — SPINA! 

IRRITATION. 

History. — It  has  been  questioned  by  several  distinguished  authors 
whether  such  an  affection  as  spinal  irritation  really  exists  as  a  distinct 
disease.  Thus  Valleix  l  ascribes  the  most  important  of  its  manifesta- 
tions to  hysteria,  and  regards  the  spinal  tenderness  present  as  being 
due  to  simple  intercostal  neuralgia  ;  Inman a  considers  the  pain  pro- 
duced by  pressure  over  the  spinous  processes  of  the  vertebrae  as  exist- 
ing in  the  muscular  attachments,  and  as  indicative  of  what  he  calls  my- 
algia. Mr.  Skey  3  evidently  looks  upon  all  cases  of  spinal  irritation  as 
hysterical  in  their  character,  and  Niemeyer 4  speaks  incredulously  on 
the  subject,  without  giving  any  very  decided  opinion.  It  would  be 
easy  to  bring  forward  other  authorities  who  have  expressed  similar 
views,  and  I  may  have  to  allude  to  some  of  them  more  fully  hereafter. 
In  the  recently-published  nomenclature  of  the  Royal  College  of  Physi- 
cians,6 the  affection  has  no  place  unless  it  be  included  under  the  head  of 
hysteria. 

The  first  author  who  distinctly  grouped  together  the  symptoms  of 

1  "Traite  des  nevralgies,  ou  affections  douloureuses  des  ncrfs,"  Paris,  1841,  p.  345. 
9  "  On  Myalgia :   its  Nature,  Causes,  and  Treatment,"  etc.,  second  edition,  London, 
1860,  p.  225,  et  seq. 

3  "  Hysteria,"  etc.,  New  York,  1867,  p.  12,  et  seq. 

4  "A  TeitBook  of  Practical  Medicine,"  American  edition,  New  York,  1869,  vol  ii. 
p.  258. 

6  "  The  Nomenclature  of  Diseases  drawn  up  by  a  Joint  Committee  appointed  by  the 
Royal  College  of  Physicians  of  London,"  London,  1869. 


SPINAL  ANEMIA.  375 

spinal  irritation  was  J.  Frank,1  who,  under  the  name  of  rachialgia,  de- 
scribed the  disorder  with  considerable  accuracy,  and  laid  the  principal 
stress  upon  the  local  pain.  He  was  followed  by  Stiebel,3  who,  however, 
contributed  little  to  our  knowledge  of  the  subject. 

Mr.  J.  R.  Player 8  was  among  the  first  English  physicians,  if  not  the 
very  first,  to  call  attention  to  the  fact  that  eccentric  derangement  of 
function  may  be  the  result  of  irritation  of  the  spinal  cord.  Thus  he 
says  :  "  Most  medical  practitioners  who  have  attended  to  the  subject 
of  spinal  disease  must  have  observed  that  its  symptoms  frequently  re- 
semble various  and  dissimilar  maladies,  and  that  commonly  the  function 
of  every  organ  is  impaired  whose  nerves  originate  near  the  seat  of  dis- 
order. The  occurrence  of  pain  in  distant  parti  forcibly  attracted  my 
attention,  and  induced  frequent  examination  of  the  spinal  column  ;  and, 
after  some  years'  attention,  I  considered  myself  enabled  to  state  that, 
in  a  great  number  of  diseases,  morbid  symptoms  may  be  discovered 
about  the  origins  of  the  nerves  which  proceed  to  the  affected  parts,  or 
of  those  spinal  branches  which  unite  them  ;  and  that,  if  the  spine  be 
examined,  more  or  less  pain  will  commonly  be  felt  by  the  patient  on  the 
application  of  pressure  about  or  between  those  vertebrae  from  which 
such  nerves  emerge." 

The  term  "  spinal  irritation  "  appears  to  have  been  first  used  by  Dr. 
C.  Brown,4  of  Glasgow,  who,  in  a  very  excellent  paper,  gives  a  picture 
of  the  disorder  which  cannot  fail  to  be  recognized  as  truthful  and  exact 
by  those  who  have  witnessed  several  cases  of  the  affection.  He  insists 
upon  not  confounding  the  complaint  with  those  organic  diseases  of  the 
vertebrae  and  spinal  cord  which  some  of  its  symptoms  cause  it  to  resem- 
ble, points  out  the  variation  of  the  phenomena  according  to  the  seat  of 
the  spinal  tenderness,  and  inculcates  the  employment  of  rest  and  coun- 
ter-irritation as  the  most  effectual  remedies.  His  ideas  of  the  patholo- 
gy of  the  disease  are  :  "  That  the  immediate  cause  of  the  pain  of  the 
buck  and  breast  is  spasm  of  one  or  other  of  the  muscles  arranged  along 
the  spine  altering  the  position  of  the  vertebrae,  or  otherwise  compress- 
ing them  as  they  issue  from  the  spinal  marrow. 

"That  this  spasm  in  many  instances  is  strictly  a  local  disease,  pro- 
duced by  fatigue,  wrong  posture,  or  other  causes,  and  quite  uncon- 
nected with  the  state  of  the  brain,  spinal  marrow,  or  nervous  system 
in  general. 

"Bui  that,  in  other  formidable  instances,  this  partial,  spasmodic,  or 
wrong  action  of  the  muscles,  is  owing  to  a  faulty  state,  perhaps  an 
enlargement,  of  the  vessels  of  the  brain  or  spinal  marrow.  This  state 
of  the  brain,  as  in  many  other  diseases,  givi  3  rise  to  spasm  or  even  to 

1  "  !>■■  Raohialgitide"  In  Prax.  mod.  univ.,  P.  II.,  t.  i.,  p.  37. 

9  "JJeber  Neurolgica  Rachitica,"  Rutft  Magazine^  t.  L,  0.  x\  i.,  p.  5-19. 

•  Quarterly  Journal  oj  I.  ill.,  p.  438.     Quoted  by  Teale. 

♦"On  Irritation  of  the  Spinal  Nerves,"    Olatgou  M  ■•/■  UJourntu\  No,  II,  May,  1828. 


37G  DISEASES  OF  THE  SPINAL  CORD. 

convulsion  of  certain  muscles  ;  which  partial  symptom,  from  its  sever- 
ity, attracts  the  chief  attention.  This  local  affection  is  confined  to 
those  portions  of  the  spine  where  there  is  the  greatest  motion,  and 
where,  of  course,  the  muscles  having  the  greatest  activity  are  most 
liable  to  deranged  action  or  spasm.  I  imagine  that  this  view  of  the 
subject  is  illustrated  and  perhaps  confirmed  by  various  symptoms  whifh 
were  observed  in  the  different  cases,  and  which  without  it  were  very 
incomprehensible.  The  partial  palsy,  the  affection  of  the  sight,  the 
giddiness  of  the  head  (for  I  find  that  this  was  a  prominent  symptom  in 
several  cases,  especially  in  that  of  A.  S.),  all  give  some  confirmation  to 
the  notion  that  the  brain  is  affected  in  these  severe  cases." 

Dr.  Darwall,1  of  Birmingham,  describes  several  features  of  the  affec- 
tion with  accuracy,  such  as  those  simulating  cardiac  and  gastric  dis- 
eases. He  is  inclined  to  believe  that  the  morbid  condition  of  the  spina] 
cord  depends  mainly  upon  irregularity  of  the  circulation,  generally 
congestion. 

But  no  essay  upon  the  subject  of  spinal  irritation,  which  had  yet 
.  appeared,  was  equal  in  thoroughness  to  that  of  Mr.  Teale,2  and  it  is  to 
him  that  the  views  now  generally  held  relative  to  the  connection  be- 
tween various  eccentric  phenomena,  such  as  pain,  spasm,  and  visceral 
disturbance,  and  a  peculiar  condition  of  the  spinal  cord,  are  to  be 
attributed.  He,  however,  committed  the  great  error  of  regarding  the 
affection  as  being  due  to  inflammation,  and,  in  what  for  those  days  was 
logical  accordance  with  this  theory,  he  combated  it  with  strong  anti- 
phlogistic measures.  His  book  may  be  studied  with  advantage,  as 
presenting  an  admirable  account  of  the  many  diverse  phases  which 
spinal  irritation  may  assume. 

Mr.  Tate,3  in  his  wTork  on  hysteria,  attributes  many  of  the  protean 
manifestations  of  this  disorder  to  spinal  irritation,  limited,  however,  to 
the  dorsal  region.  He  fails  to  recognize  it  as  an  independent  disease. 
His  treatment  consists  in  the  application  of  tartar-emetic  ointment 
along  the  whole  length  Of  the  dorsal  vertebrae,  and  strong  purgation. 
He  discountenances  the  use  of  leeches  and  blisters. 

Mr.  W.  It.  Whatton  *  insists  chiefly  upon  the  liability  to  mistake 
spinal  irritation  for  disease  of  the  vertebras.  He  gives  a  very  excellent 
account  of  the  symptoms.  The  treatment  he  recommends  consists  in 
the  abstraction  of  blood,  by  leeches  or  cups,  from  the  parts  where  the 
tenderness  is  felt,  repeated  every  three  or  four  days,  and  the  applica- 

1  "  On  some  Forms  of  Cerebral  and  Spinal  Irritation,"  Midland  Medical  Reporter, 
May,  1829. 

*  "  A  Treatise  on  Neuralgic  Diseases  dependent  upon  Irritation  of  the  Spinal  Marrow 
and  Ganglia  of  the  Sympathetic  Nerve,"  London,  1829. 

3  "Treatise  on  Hysteria,"   London,  1830. 

4  "On  Spinal  and  Spiuo-Ganglial  Irritation,"  North  of  England  Medical  and  Surgical 
Journal,  No.  III.,  1831. 


SPINAL  ANEMIA.  377 

tion  of  small  blisters  on  each  side  of  the  painful  spots.  Any  debility 
ensuing  in  consequence  of  this  treatment  is  to  be  remedied  by  the  prep- 
arations of  iron  and  quinine. 

In  a  clinical  lecture  delivered  in  Dublin,  Dr.  Corrigan '  relates  the 
particulars  of  several  cases  of  spinal  irritation,  successfully  treated  by 
local  antiphlogistic  measures,  and  the  internal  use  of  iron.  He  does 
not,  however,  add  any  thing  of  importance  to  our  previous  knowledge 
of  the  subject. 

Dr.  Isaac  Parish,9  of  Philadelphia,  appears  to  have  been  the  first 
American  author  who  called  attention  to  the  affection  in  question.  He 
relates  the  details  of  several  cases,  recommends  the  use  of  counter- 
irritants,  especially  tartar-emetic  ointment,  and  concludes  : 

"  First,  that  tenderness  on  pressure  in  some  portion  of  the  spinal 
cord  is  an  attendant  on  many  chronic  neuralgic  affections,  and  that,  by 
relieving  it  in  the  manner  proposed,  these  complaints  are  either  entirely 
eradicated  or  temporarily  suspended. 

"  And,  secondly,  that  the  precise  indications  which  this  circumstance 
affords  are  not  sufficiently  understood  at  the  present  time  to  justify  the 
establishment  of  any  definite  pathological  principles  applicable  to  the 
whole  class  of  neuroses." 

Dr.  W.  Griffin  and  his  brother,  Mr.  D.  Griffin,3  of  Limerick,  were 
the  next  to  write  upon  the  subject.  The  joint  work  of  these  gentlemen 
is  based  upon  one  hundred  and  forty-eight  cases,  all  of  which  are  thor- 
oughly analyzed,  and  from  which  very  definite  deductions  of  pathology 
and  treatment  are  drawn.  The  essay  is  not  excelled  in  importance  by 
any  previous  contribution,  and  constitutes  a  really  valuable  study.  The 
conclusions  which  they  draw  are  so  instructive  that  I  do  not  hesitate 
(though  by  no  means  indorsing  them  all)  to  transfer  them  without 
abbreviation  : 

"1.  That  tenderness  at  one  or  more  points  of  the  spine  is  an  at- 
tendant on  almost  all  hysterical  complaints,  on  numerous  cases  of  func- 
tional disorder  when  the  hysteric  disposition  is  not  so  obvious,  and  in 
many  n<rvous  or  neuralgic  affections. 

";.'.  That  many  of  the  symptoms  of  these  affections  evidently  depend 
upon  a  peculiar  state  of  certain  nerves,  probably  at  their  origin,  may  be 
reproduced  at  any  moment  by  pressure)  and  are  often  relieved  by  rem- 
edies applied  there. 

Hut,  in  ,,U  oases  of  tenderness  of  the  oervioal  and  upper  dorsal 
spine,  there  was  nausea,  <>r  vomiting,  or  pain  of  stomach,  or  affections 

1  Medico- Chiruroieal  Review,  July,  1881,  | 

8  "  I!'  9pinal  Irritation  as  connected  with  Nervous  Diseases:  with  I 

-'  ■"  Journal  of  tin-  Mod  »,  vol.  x.,  1882,  p.  228. 

* "  Qhservations  on  the  Functional  affections,  of  the  Spinal  Cord  ami  Qai 
Nerves,  in  which  their  Identity  with  Sympathetic,  Nervous,   ind  Simulated  Diseases  is 

UldStr;'!      I,       I  .     i.,    I  -..I. 


378  DISEASES  OF  THE  SPINAL  CORD. 

of  the  upper  extremities  ;  but  no  pain  of  the  abdomen,  dysury,  ischury, 
hysteralgia,  or  affections  of  the  lower  extremities. 

"  4.  That,  in  all  cases  of  dorsal  tenderness,  pains  affecting1  the  abdo- 
men, bladder,  uterus,  testes,  or  lower  extremities,  were  usual  symp- 
toms ;  while  nausea,  vomiting1,  or  affections  of  the  upper  extremities, 
were  never  complained  of. 

"5.  That  nausea  and  vomiting  appeared  to  have  more  relation  to 
tenderness  of  the  cervical  spine,  pain  of  stomach  to  tenderness  of 
dorsal  ;  but  that,  when  there  was  soreness  of  both,  nausea  or  vomit- 
ing was  still  more  frequent,  and  pain  of  the  stomach  scarcely  ever  absent. 

"  6.  That,  when  several  points  or  a  great  extent  of  the  spinal 
column  is  painful  and  tender  on  pressure,  local  remedies  are  generally 
less  effectual,  and  there  is  a  strong  disposition  to  transference  of  the 
disordered  action  from  one  organ  to  another ;  the  pain  or  tenderness 
in  all  such  cases  of  transference,  shifting  its  place  to  a  corresponding 
part  of  the  spinal  column,  leaving  the  original  point  free,  or  with  a  very 
diminished  degree  of  tenderness. 

"  7.  That  spinal  tenderness  is  seldom  or  never  met  with  in  cases  of 
pure  inflammation,  except  when  these  accidentally  occur  in  persons 
previously  suffering  from  irritation  of  the  cord  ;  and  that,  when  appear- 
ances of  inflammation  present  themselves  in  any  organ  accompanied  by 
a  corresponding  spinal  tenderness,  they  cannot  commonly  be  removed 
by  the  remedies  applicable  to  inflammatory  cases,  and  are  often  ren- 
dered worse  by  them. 

"  8.  That  there  does  not  appear  to  be  a  complaint  to  which  the  human 
frame  is  liable,  whether  inflammatory  or  otherwise,  which  may  not  be 
occasionally  imitated  in  disturbed  states  of  the  cord  ;  and  hence  that 
this  disturbed  state  is  one  vast  source  of  those  complaints  called  hyster- 
ical or  nervous. 

"  9.  That  those  functional  disorders  connected  with  spinal  tenderness 
are  very  often  attended  by  some  disturbance  of  the  functions  of  the 
uterus,  but  that  they  are  by  no  means  always  so,  since  they  occur  in 
those  who  are  regular  in  this  respect :  in  girls  long  before  the  menstrual 
period  of  life,  in  women  after  it  has  passed,  and,  lastly,  in  men  of  ner- 
vous susceptible  habits,  and  in  boys. 

"  10.  That  in  fact  they  are  not  necessarily  dependent  upon  any  one 
organ  ;  since  they  are  found  indifferently  coexisting  with  disturbance 
of  the  digestive  organs  solely,  or  the  uterus  solely,  or  of  the  circulatory 
or  respiratory  system. 

"  11.  That  from  the  cases  detailed  we  have  reason  to  suppose  spinal 
tenderness  may  arise  from  uterine  disorder,  from  dyspepsia,  from  worms 
in  the  alimentary  passages,  from  affections  of  the  liver,  from  mental 
emotions,  from  the  poison  of  typhus,  from  marsh  miasmata,  from  erysipe- 
latous, rheumatic,  and  eruptive  fevers,  and  from  the  irritation  arising 
from  local  injury. 


SPINAL   ANEMIA.  379 

"12.  That  it  is  almost  invariably  found,  in  connection  with  gastric 
or  abdominal  tenderness,  in  fever  ;  and  this  tenderness  is,  probably,  like 
the  soreness  of  scalp,  pains  in  the  limbs,  etc.,  dependent  on  the  morbid 
state  of  the  cord. 

"  13.  That,  whether  in  fever  or  in  other  complaints,  it  is  met  with 
in  the  situation  of  the  eighth  or  ninth  dorsal  vertebra  much  more  fre- 
quently than  at  any  other  part  of  the  spine. 

"  14.  That  affections  attended  by  spinal  tenderness  are  seldom  fatal  ; 
that,  even  in  those  cases  of  intense  irritation  of  the  cord  under  which 
patients  suffer  extremity  of  pain  for  years,  the  event  is  generally  favor- 
able. 

"  15.  That  they  frequently,  as  well  as  hysteria,  occur  with  all  the 
appearances  of  a  primary  affection  of  the  nervous  system. 

"1G.  That  affections  are  occasionally  met  with  presenting  all  the 
marks  of  the  hysteric  character,  and  perfectly  resembling  cases  described 
as  those  of  spinal  irritation,  but  unattended  by  spinal  tenderness  or  any 
jther  direct  indication  of  a  morbid  state  of  the  cord." 

The  treatment  recommended  consists  in  the  removal  of  the  cause  if 
this  still  continues  in  action,  purgatives,  the  application  of  blisters  and 
leeches  to  the  skin,  the  internal  administration  of  hyoscyamus  and  bel- 
ladonna, to  lessen  the  nervous  irritability,  alum  in  cases  of  gastric  de- 
rangement, and  change  of  air  and  scene. 

In  a  subsequent  work,  the  Messrs.  Griffin !  again  discuss  the  sub- 
ject, but  bring  forward  no  additional  facts. 

Dr.  John  Marshall8 is  confident  that  many  visceral  affections,  such 
as  heart-diseases,  asthma,  phthisis,  dyspepsia,  diabetes,  chorea,  and  e\  en 
phlegmasia  dolens,  are  frequently  really  produced  or  simulated  by  spi- 
nal irritation.  Some  of  his  cases  of  supposed  functional  disorder  of  the 
spinal  cord  are,  however,  obviously  organic,  consisting  of  congestion, 
inflammation,  or  softening  of  the  organ. 

In  his  classical  work,  Ollivier  8  devotes  considerable  space  to  what 
he  calls  "an  Affection  described  under  the  name  of  Spinal  Irritation." 
He  considers  the  pathological  condition  to  be  one  of  congestion  of  the 
meninges  of  the  cord,  and  bases  this  opinion  in  great  part  on  the  suc- 
cess which,  according  to  him,  ensues  on  the  use  of  leeches,  blisters,  and 
counter-irritant  ointments.  In  addition,  he  favors  the  administration 
of  opium,  digitalis,  hyoscyamus,  belladonna,  and  suboarbonate  of  iron. 

Ttlrck4  regards  the  phenomena  of  spinal  irritation  as  being  due, 

'"Medical  and  Physiological  Problems:  being  chiefly  B  for  Correct  Primi- 

oeni  in  Disputed  Points  of  Medical  Practice,"  London,  1846. 

»  u  Practical  Observations  on  Discnses  of  the  Heart,  Lungs,  Stomach,  Liver,  etc,  oc- 
casioned by  Spinal  [rritation,  and  on  the  Nervous  Bystem  In  General  at  of  Or- 
ganic  Disease,"  London,  1*35. 

•  "Tralte"  dee  maladies  de  la  moelle  eplniere,"  troisleme  Edition,  Paris,  1887,  tome 
seconde,  p.  209. 

4  "AbbuiiJlung  liber  6plual  Irritation,"  u.  s.  w.,  Wlen,  1843. 


380  DISEASES   OF  THE  SPINAL   CORD. 

first,  to  disorder  of  other  organs,  whereby  a  morbid  impression  ia 
propagated  along  the  incident  excitor  nerves  to  the  spinal  cord ;  or, 
second,  to  derangement  of  the  capillary  circulation  of  the  cord.  That 
is,  the  disease  may  be  either  of  eccentric  or  centric  origin.  He  does  not 
advance  our  knowledge  beyond  the  point  reached  by  previous  authors. 

Coming  again  to  our  own  country,  we  find  that  in  1844  a  very  valu- 
able paper  was  published  by  Prof.  Austin  Flint,1  based  upon  fifty-eight 
cases  of  functional  disorder  connected  with  an  abnormal  condition  of 
the  spinal  cord.  In  this  memoir,  without  going  into  any  discussion  rela- 
tive to  the  pathology  of  the  affection,  Dr.  Flint  considers  the  disorder 
as  giving  rise  to  tenderness  over  the  vertebral  column,  causing  altera- 
tions of  sensibility,  as  affecting  the  muscular  system,  as  producing  abnor- 
mal mental  manifestations,  as  affecting  the  digestive  organs,  the  genito- 
urinary organs,  the  heart  and  circulation,  and  as  causing  paroxysms  of 
sinking.  He  then  considers  the  physical  habits  of  the  patients,  the  re- 
sults of  medical  treatment,  the  probable  remote  causes,  and  then,  at 
some  length,  the  remedial  measures  which  he  has  found  most  successful. 
Under  this  head,  Dr.  Flint  advises  the  use  of  counter-irritants  to  the 
spine,  especially  cupping,  and  generally  without  scarification.  Issues 
he  found  inapplicable,  death  ensuing  in  the  one  case  in  which  he  used 
them.  There  is  no  doubt,  however,  that  in  this  instance  he  had  an  or- 
ganic disease  to  deal  with,  and  that  the  issues  had  nothing  to  do  with 
the  fatal  result.  Tonics,  especially  iron,  he  found  to  be  of  great  advan- 
tage. 

In  a  very  full  analysis  of  the  medical  reports  of  the  Stockholm  Hos- 
pital by  Dr.  Magnus  Huss,2  the  subject  of  spinal  irritation  receives  due 
consideration.  Dr.  Huss  classes  the  symptoms  of  the  disorder  as  fol- 
lows :  1.  Pain  of  various  parts  of  the  vertebral  column,  existing  either 
idiopathically  or  developed  by  pressure.  2.  Cramps,  either  of  a  clonic 
or  tonic  nature,  in  those  parts  subjected  to  the  influence  of  the  spinal 
cord.  3.  Loss  of  power  in  the  same  portions  of  the  body,  ranging  from 
simple  stiffness  and  weakness  to  complete  paralysis.  4.  Altered  sensi- 
bility, either  by  excess  or  by  great  diminution  of  sensation. 

It  will  be  observed  that  in  this  enumeration  the  author  confines  his 
specification  of  morbid  phenomena  to  those  which  relate  to  sensation 
and  the  power  of  motion. 

The  treatment  is  fully  and  philosophically  considered.  Of  external 
remedies  he  prefers  counter-irritants,  using  the  milder  forms  first,  and 
then  the  severer,  such  as  the  moxa  and  the  actual  cautery,  should  the 
first  fail.  Venesection,  either  general  or  local,  should  be  cautiously 
employed,  and  is  not  generally  indicated.  He  is  the  first,  so  far  as  my 
researches  extend,  to  mention  electricity,  a  means  which  he  thinks  may 

1  "Observations  on  the  Pathological  Relations  of  the  Medulla  Spinalis,"  American 
Journal  of  the  Medical  Sciences,  April,  1844,  p.  269. 

8  British  and  Foreign  Medical  Review,  October,  1846,  p.  463. 


SPINAL  ANEMIA.  381 

be  employed  with  advantage  in  chronic  and  debilitated  cases.  Potash- 
baths  are  also  recommended. 

Of  internal  remedies  he  specifies  iron,  opium,  strychnia,  phosphorus, 
and  valerian,  as  being  preeminently  useful. 

Axenfeld  '  devotes  a  considerable  portion  of  his  treatise  to  spinal 
irritation.  He  regards  it  as  being  produced  either  by  a  trouble  of  in- 
nervation or  congestion.  In  the  treatment,  leeches  occupy  the  first 
place,  and  in  light  cases  blisters,  sinapisms,  dry  cups,  and  stimulating 
frictions,  are  useful.  Internally  he  recommends  nothing  but  quinine 
and  iron. 

Dr.  Radcliffe s  writes  very  sensibly  on  the  subject  of  spinal  irrita- 
tion, and  gives  a  typical  case  which  is  quite  instructive.  He  incident- 
ally gives  it  as  his  opinion,  that  the  pathological  condition  is  one  of 
anaemia,  and  he  consequently  discourages  the  use  of  leeches,  relying 
mainly  on  blisters  and  tonics. 

Leyden  3  declines  to  recognize  spinal  irritation  as  a  distinct  patholo- 
gical entity,  regarding  it  as  a  condition  which  may  result  from  other 
primary  affections.  In  this  he  very  generally  mistakes  cause  for  effect. 
His  remarks  are  evidently  more  based  on  theory  than  practice,  for  it  is 
very  apparent  he  has  seen  little  or  nothing  of  the  disorder  under  con- 
sideration. 

Rosenthal  *  barely  mentions  it  under  the  head  of  hysteria. 

Erichsen,5  with  more  practical  acumen,  says  of  spinal  ansemia,  and 
especially  of  ansemia  of  the  posterior  columns  of  the  cord,  that  it  is 
"  a  condition  which  we  rather  recognize  clinically  than  pathologically, 
by  analogy  than  by  direct  post-mortem  demonstration,  by  therapeutical 
rather  than  by  physiological  tests.  But  yet  it  is  a  condition  which  is 
now  fully  recognized  as  probable,  in  lieu  of  positive  evidence,  by  the 
best  and  most  modern  writers  on  nervous  diseases,  and  one  the  prob- 
able  existence  of  which  we  may  accept." 

I  have  thus  cited  the  principal  authorities  upon  spinal  irritation, 
without,  however,  by  any  means,  exhausting  the  bibliography  of  the 
subject.  Notwithstanding  the  eminence  of  many  of  those  who  have 
oonti  tided  lor  the  existence  of  a  definite  affection  of  the  spinal  cord, 
characterized  by  tenderness  on  pressure  over  one  or  more  of  the  verte- 
bras, and  certain  eccentric  disorders  involving  sensibility,  tin-  power  of 
motion,  and  functional  derangement  of  many  of  the  viscera,  it  must  be 
confessed  that  the  great  mass  of  the  medical  prof ession  has  regarded 

tin-  whole    theory    with    suspicion,  it    not    with    absolute    distrust.      The 

1  "  Dcs  Nevrosei,"  Paris,  1868,  p.  284. 

s  Reynolds's  "System  of  Medicine,"  London,  1868,  vol  ii.,  p.  640. 
•  "Klinik  der  RQckenmarks-Krankheiten,"  zweiter  Band,  orate  Abtheilung,  Berlin, 
1375,  ji.  1,  <f  s,  ,j. 

«  ■■  Klinik  der  tferven-Krankheiten,"  Stuttgart,  1878,  p.  4  K). 

6  "On  Concussion  of  the  Spin-,"  ate.,  London,  1^75,  p.  188,  a  ttq. 


382  DISEASES  OF  THE  SPINAL  CORD. 

principal  reason  for  this  is  undoubtedly  to  be  found  in  the  fact  that, 
like  many  other  new  theories,  that  of  spinal  irritation  has  been 
applied  to  explain  conditions  which  it  could  not  logically  be  made  to 
cover.  Thus  many  cases  of  disease  or  disorder  of  the  heart,  due  to 
organic  difficulties  of  that  organ,  or  excited  by  disease  of  other  viscera 
through  the  sympathetic  system,  have  been  attributed  to  spinal  irrita- 
tion. The  same  is  true  also  of  the  uterus,  stomach,  liver,  and  other 
organs,  and  even  of  the  spinal  cord  itself,  which  often,  when  the  seat 
of  organic  diseases,  such  as  congestion,  meningitis,  inflammation,  tu- 
mors, etc.,  has  been  regarded  as  simply  in  a  state  of  irritation.  It  is 
very  certain,  also,  that  numberless  cases  of  hysteria  have  been  attrib- 
uted to  irritation  of  the  spinal  cord.  In  the  following  remarks  I  will 
endeavor  to  be  as  explicit  as  possible,  and  not  to  claim  too  much  for  a 
pathological  condition  which  I  am  very  sure  exists,  and  which  I  there- 
fore think  is  entitled  to  recognition.  If  I  contribute  any  additional 
information,  it  will  be  mainly  due  to  the  fact  that  our  means  of  exami- 
nation are  much  more  perfect  and  extensive,  and  our  knowledge  of 
physiology,  pathology,  and  therapeutics,  more  thorough  than  when 
most  of  the  authors  I  have  quoted  wrote  upon  the  subject.  My  observa- 
tions are  based  upon  a  careful  study  of  one  hundred  and  twenty-seven 
cases  which  have  occurred  in  my  private  practice  during  the  last  six 
years,  and  of  which  I  have  full  notes,  and  twenty-nine  cases  of  which  I 
have  less  complete  data — in  all,  one  hundred  and  fifty-six  cases.1 

Symptoms. — Centric  Symptoms. — 1.  Tenderness  at  some  one  or 
more  Points  over  the  Spinal  Column,  increased  by  Pressure. — This  is 
the  essential  symptom  of  spinal  irritation,  though  varying  in  intensity 
from  the  slight  degree  of  pain  experienced  upon  strong  pressure  to  the 
acute  hyperassthesia  which  does  not  allow  of  even  the  contact  of  the 
clothing  without  the  production  of  great  suffering.  It  is  generally  com- 
plained of  by  the  patient,  though  occasionally  it  has  to  be  sought  for 
by  the  physician.  The  brothers  Griffin  found  this  symptom  present 
in  all  but  five  out  of  one  hundred  and  forty-eight  cases,  and  it  is  very 
probable  that  these  five  were  not  cases  of  spinal  irritation,  a  supposi- 
tion which  the  authors  themselves  evidently  entertain.  Certainly  the 
details  of  the  cases  do  not  support  the  view  which  would  ascribe  their 
phenomena  to  any  affection  of  the  spinal  cord.  Most  of  the  other 
authors  I  have  cited  refer  to  this  tenderness  as  a  prominent  feature. 
Parish  thinks  it  alone  is  to  be  relied  upon  as  indicating  irritation;  Mr. 
Whatton  declares  that  it  is  never  wanting  ;  Axenf  eld  regards  it  as 
the  dominant  and  characteristic  symptom  ;  and  Radcliffe,  while  admit- 
ting that  it  is  not  equally  well  marked  in  every  case,  states  the  rule  to 
be  that  spinal  tenderness  and  spinal  irritation  go  together. 

1  Since  the  first  edition  of  this  work  was  published,  a  large  additional  number  of 
cases  of  spinal  congestion  have  come  under  my  notice,  but,  as  I  have  kept  no  full  record 
oi"  them,  I  have  allowed  the  statement  in  the  text  to  remain  unaltered. 


SPINAL  ANAEMIA.  383 

On  the  other  hand,  Flint  does  not  regard  tenderness  as  an  invari- 
able and  essential  element  of  the  affection  under  consideration.  He 
found  it  absent  or  indistinct  in  five  of  his  fifty-eight  cases,  while  the 
other  attendant  circumstances  furnished  unequivocal  evidence  that  the 
diagnosis  was  correct. 

My  own  opinion  would  lead  me  to  consider  no  case  as  one  of  spinal 
irritation  in  which  tenderness  on  pressure  over  the  vertebrae  was  ab- 
sent. In  the  one  hundred  and  fifty-six  cases  noted  by  me,  this  symptom 
was  present  in  all.  There  are  diseases  of  the  spinal  cord,  which  pro- 
duce derangements  of  other  organs  of  the  body,  and  which  are  not 
characterized  by  vertebral  tenderness,  but  these  are  far  more  serious 
affections  than  spinal  irritation,  and  of  altogether  different  pathology. 

The  seat  of  the  tenderness  is  'generally  in  the  dorsal  region  of  the 
spine.  The  Griffins  found  cervical  tenderness  in  twenty-three  cases, 
cervical  and  dorsal  tenderness  in  forty-six,  dorsal  alone  in  twenty-three, 
dorsal  and  lumbar  in  fifteen,  lumbar  in  thirteen,  the  whole  spine  tender 
in  twenty-three,  and  no  tenderness  in  five.  Of  one  hundred  and  forty- 
eight  cases,  therefore,  one  hundred  and  seven  exhibited  tenderness  in 
the  dorsal  region. 

Dr.  Flint  found  cervical  and  dorsal  tenderness  in  three  cases,  lum- 
bar and  dorsal  in  ten,  and  dorsal  alone  in  twenty-one  cases. 

Of  my  own  cases,  twenty-five  had  cervical  tenderness  only,  thirty- 
seven  cervical  and  dorsal,  forty-five  dorsal  only,  nineteen  dorsal  and 
lumbar,  fifteen  lumbar  only,  and  in  fifteen  the  whole  spine  was  tender. 
One  hundred  and  sixteen  cases,  therefore,  of  one  hundred  and  fifty-six 
were  characterized  by  dorsal  tenderness,  and  in  forty-five  it  was  limited 
to  this  region. 

The  degree  and  character  of  the  tenderness  are  subject  to  great 
variation.  In  some  cases  strong  pressure  is  required  to  develop  it, 
while  in  others  the  least  touch  is  insupportable.  Sometimes  there  are 
shooting  pains,  which  radiate  from  the  tender  spot,  while  at  others  the 
hyperesthesia  is  quite  circumscribed.  In  a  gentleman  now  under  my 
care  with  well-marked  spinal  irritation,  and  who  has  a  tender  spot  over 
the  third  lumbar  vertebra,  pressure  not  only  causes  intense  suffering  at 
that  point,  but  develops  pain  along  the  whole  course  of  the  crural  nerves 
and  their  branches  as  Ear  as  their  terminations  on  the  inner  sides  of  the 
feet.  Another,  a  lady,  who  has  spinal  tenderness  over  the  eighth  cer- 
vical  and  first  dorsal  vertebrae,  experiences,  from  pressure,  intense  pain 
along  the  course  of  the  firsl  intercostal,  the  internal  anterior  thor 
and  all  the  nerves  of  the  left  upper  extremity.  Why  in  these  and  other 
,  particular  nerves  should  be  affected,  is  a  question  which  will  be 

more  fully  considered  herea  I'ter. 

The  pain  developed  by  pressure  is  no!  always  of  the  same  character. 
Sometimes  it  is  dull  and  aohing,  and  at  others  sharp  and  lanoinating. 
I  have  not    noticed  that   any  very  definite  relation  exists  between  the 


384  DISEASES  OF  THE  SPINAL  CORD. 

character  of  the  pain  and  the  severity  of  the  other  symptoms,  though, 
as  regards  the  degree  of  pain  of  each  kind,  there  is  a  marked  connec- 
tion. By  this  I  mean  that  a  dull,  aching  sensation  may  indicate  as  pro- 
found a  pathological  condition,  and  be  accompanied  by  as  intense  eccen- 
tric phenomena,  as  a  sharp  and  lancinating  pain,  though  a  severe  ach- 
ing pain  and  a  severe  lancinating  pain  always  indicate  more  serious  dis- 
order than  when  these  sensations  are  not  so  emphatic. 

The  character  of  the  pain  varies  in  accordance  with  the  tissue  in 
which  it  is  felt.  The  dull  aching  sensation  is  only  developed  by  strong 
pressure,  and  is  seated  in  the  muscular,  tendinous,  or  cartilaginous 
structures  about  the  vertebra?.  The  sharp,  piercing  twinges  excited  by 
slight  pressure  arise  from  the  skin,  and  subcutaneous  cellular  tissue. 
With  these  species  of  sensations,  the  assthesiometer  always  shows  in- 
creased sensibility  of  the  skin  over  and  in  the  vicinity  of  the  painful 
centres. 

To  ascertain  whether  or  not  the  tissues  outside  of  the  spinal  canal 
are  in  a  state  of  hyperesthesia,  the  pressure  should  be  applied  with 
gradually-increasing  force,  by  means  of  the  thumbs  applied  to  the 
spinous  processes  and  the  intervertebral  spaces,  as  recommended  by 
Flint.  The  examination  should  be  thorough,  and  extend  throughout 
the  whole  extent  of  the  vertebral  column.  The  fact  that  the  patient 
denies  the  existence  of  tenderness  should  have  no  weight  with  the  phy- 
sician. Only  a  few  days  ago  a  young  lady  consulted  me  for  severe 
infra-mammary  pain,  headache,  and  nausea.  I  at  once  suspected  spinal 
irritation,  but  she  declared,  in  answer  to  my  inquiries,  that  there  was 
no  sign  of  tenderness  anywhere  over  the  spinal  column.  I  insisted, 
however,  on  a  manual  examination,  and  to  her  great  surprise  found 
three  spots  that  were  exceedingly  painful  to  slight  pressure.  This 
young  lady  had  been  treated  for  dyspepsia  for  several  years,  without 
deriving  any  benefit  from  the  measures  used,  but  was  cured  by  the 
treatment  which  I  shall  presently  fully  consider.  Occasionally  it  hap- 
pens that  the  tenderness  is  not  perceived  for  some  time  after  the  press- 
ure is  made.  In  a  recent  case  I  found  the  interval  to  be  over  a  min- 
ute, and  then  acute  pain,  following  the  course  of  the  nerves,  was  ex- 
perienced. I  am  not  prepared  to  offer  an  explanation  of  this  phenome- 
non. 

2.  Pain  in  the  Spinal  Cord. — The  tenderness  just  noticed  is  seated 
primarily  externally  to  the  vertebral  canal,  and  is  developed  by  press- 
ure. That  which  is  now  to  be  considered  is  located  in  the  spinal  cord, 
and  is,  therefore,  capable  of  being  produced  by  pressure  upon  non-ten- 
der spots.  It  is  a  very  common  symptom,  having  been  present  in  one 
hundred  and  one  of  my  cases.  Generally  it  is  confounded  with  spinal 
tenderness,  from  which,  however,  it  is  quite  distinct.  It  is  aggravated 
by  motion  of  the  spinal  column,  by  action  of  the  muscles  which  have 
their  attachments  to  the  spinous  and  transverse  processes,  by  percus- 


SPINAL  ANEMIA.  385 

sion,  and  sometimes  by  the  erect  posture.  In  the  case  of  a  gentleman 
of  this  city,  it  was  so  great  when  he  stood  up  that  he  was  forced  to  keep 
the  recumbent  position  nearly  the  whole  time.  When  I  first  saw  him 
he  was  wearing  an  apparatus  designed  to  keep  the  weight  of  the  head 
from  the  vertebral  column,  and  to  prevent  the  vertebras  pressing  upon 
each  other,  under  the  idea  that  he  had  disease  of  the  intervertebral  sub- 
stance. I  removed  the  instrument,  and,  treating  him  for  spinal  irrita- 
tion, he  recovered  his  health  in  a  few  weeks. 

Pain  in  the  spinal  cord,  in  the  disorder  under  consideration,  is  usu- 
ally seated  near  the  point  of  external  tenderness,  though  it  is  often  at 
a  distance,  and  sometimes  is  felt  throughout  the  whole  extent  of  the 
cord.  The  eccentric  phenomena  bear  a  distinct  anatomical  and  physio- 
logical relation  to  it,  as  do  those  which  are  connected  with  spinal  ten- 
derness. There  is  likewise  a  similar  connection  existing  between  the 
pain  in  the  cord  and  the  vertebral  tenderness. 

To  ascertain  the  existence  of  spinal  pain,  when  it  is  not  spontane- 
ously felt  or  superinduced  by  muscular  exertion,  percussion  should  be 
practised.  The  ends  of  the  fingers  will  answer  for  this  purpose,  though 
I  prefer  a  little  vulcanized  India-rubber  hammer,  and  a  plessimcter,  such 
as  are  sometimes  used  for  percussing  the  chest.  Even  over  spots  which 
exhibit  much  tenderness,  the  deep-seated  pain  in  the  cord  itself  can 
clearly  be  distinguished. 

Eccextmc  Symptoms. — By  far  the  most  important  and  noticeable 
symptoms  of  spinal  irritation  are  to  be  found  in  distant  parts  of  the 
body.  These  vary  in  their  character  and  seat,  according  to  the  part  of 
the  spinal  cord  affected.  Following  the  example  of  the  Griffins,  I  shall 
consider  these  symptoms  as  they  depend  upon  irritation  of  the  several 
regions  of  the  cord  with  which  they  are  connected. 

a.  The  Cervical  Region. — Of  the  cases  upon  which  this  chapter  is 
based,  in  twenty-five  the  irritation  existed  in  the  cervical  region  only, 
of  the  spinal  cord  ;  in  thirty-seven,  the  cervical  tenderness  was  con- 
joined with  dorsal  tenderness,  and  in  fifteen  with  tenderness  of  the 
whole  spine.  Taking  the  uncomplicated  cases  as  presenting  the  clear- 
est features,  the  following  would  appear  to  be  the  more  prominent 
symptoms  of  cervical  spinal  irritation. 

\  '<  rlirjo  was  an  accompaniment  in  eleven  cases,  and  headache  in 
fifteen  ;  noises  in  the  ears  in  eight,  and  disturbances  of  vision  in  four. 
JflUlness  and  a  sense  of  constriction  across  the  forehead  were  complained 
of  in  several  cases,  as  was  also  tenderness  of  the  scalp.  In  addition, 
tli''  mind  was  more  or  less  affected  in  every  case,  and  in  seven  the  ab- 
erration was  of  such  a  character  as  almost  to  amount  to  insanity.  In 
one  of  these,  a  married  lady,  aged  thirty,  there  were  Bev<  raJ  paroxysms 
of  maniacal  excitement  every  day;  and  in  another,  that  of .  a  young 
lady  aged  twenty-three,  so  furious  were  the  exacerbations  that,  for  tear 
she  would  injure  herself  or  others,  she  hail  to  be  restrained   by   twe 


386  DISEASES  OF  THE   SPINAL   CORD. 

strong  nurses,  who  held  her  while  the  fits  lasted.  The  predominant 
type,  however,  was  melancholia. 

Sleep  was  deranged  in  every  case,  generally  in  the  form  of  insomnia, 
though  in  three  cases  the  tendency  to  somnolence  was  excessive.  In 
every  case  the  dreams  were  of  an  unpleasant  character ;  in  two  there 
was  nightmare,  and  in  one  somnambulism. 

Neuralgic  pains  were  present  in  seventeen  of  the  twenty-five  cases. 
If  the  upper  part  of  the  cervical  region  was  the  seat  of  the  irritation, 
these  pains  were  experienced  in  the  scalp  and  face  ;  if  the  lower,  they 
were  seated  in  the  neck,  the  shoulders,  upper  part  of  the  chest,  and  the 
upper  extremities.  Sometimes  the  pain  was  of  a  dull,  burning  charac- 
ter, and  was  then  generally  seated  in  the  muscles  of  the  nucha.  Mus- 
cular effort  always  increased  the  suffering.  In  accordance  with  Teale's 
experience,  it  several  times  occurred  that  the  neuralgia  was  intermit- 
tent, the  paroxysms  coming  on  about  sundown  and  lasting  through  the 
night.     In  none  of  these  cases  was  there  anaesthesia. 

Motility  was  interfered  with  in  eighteen  cases.  Sometimes  there 
were  fibrillary  twitching 's /  in  five  cases  there  were  clonic  sp>asms  of 
the  muscles  of  the  face  and  neck  ;  in  three,  general  chorea  ;  in  two, 
contractions  of  the  flexors  of  the  arm  on  one  side,  so  that  the  elbow 
was  rigidly  bent ;  in  two,  the  contractions  were  in  the  flexors  of  the 
hands,  and  in  four,  of  the  fingers.  In  one  case  there  was  complete  loss 
of  power  over  the  hand  ;  in  four,  aponia  /  and  in  one,  almost  constant 
hiccough  while  the  patient  was  awake. 

Nausea  was  present  more  or  less  in  fifteen  cases,  and,  in  one,  part 
of  every  thing  taken  into  the  stomach  was  almost  immediately  rejected. 
Pain  in  the  stomach  was  not  met  with  in  any  case. 

b.  The  Dorsal  Region. — I  found  the  dorsal  region  of  the  spine  ten- 
der in  one  hundred  and  sixteen  cases.  In  thirty-seven  of  these  it  was 
conjoined  with  cervical,  in  nineteen  with  lumbar  tenderness,  and  in  fif- 
teen it  was  affected  with  the  whole  spine,  leaving  forty -five  uncompli- 
cated cases. 

The  most  prominent  symptoms  in  these  cases  were  connected  with 
the  viscera,  the  stomach  being  the  organ  commonly  involved.  Thus, 
gastralgia  was  present  in  every  case,  nausea  and  vomiting  in  nine  cases, 
pyrosis  in  three,  gastric  flatulence  in  forty,  and  acidity ',  as  evidenced 
by  heartburn,  in  twenty-six. 

Next  in  order  came  the  heart.  There  were  palpitations  in  twenty- 
six  cases,  fits  of  oppression,  during  which  the  heart  beat  with  irregu- 
larity as  regarded  force  and  rhythm,  in  ten  cases,  and  attacks  of  syn- 
cope in  five.  There  was  difficulty  of  breathing  in  fifteen  cases,  and 
cough  in  fifteen.  Intercostal  neuralgia  existed  in  ten,  and  infra- 
mammary  pain  in  thirty-one  cases. 

There  were  no  muscular  spasms,  contractions,  or  paralysis. 

In  the  thirty-seven  cases  in  which  the  dorsal  tenderness  was  con- 


SPINAL   A2LEMIA.  387 

joined  with  cervical  tenderness,  the  symptoms  characteristic  of  each 
region  were  more  or  less  intermingled.  In  two  cases  there  was 
epilepsy,  and  in  three  chorea  paralytica. 

c.  The  Lumbar  Region. — This  portion  of  the  spine  exhibited  ten- 
derness in  forty-nine  cases.  In  nineteen  of  these  it  was  accompanied 
by  dorsal  tenderness,  in  fifteen  the  whole  spine  was  affected,  and  in  fif- 
teen the  tenderness  was  confined  to  the  lumbar  region  alone.  Of  these 
latter  all  were  characterized  by  neuralgic  pains  in  the  lower  extremi- 
ties, and  in  three  of  them  there  were  similar  pains  in  the  muscles  cf 
the  back  and  abdomen.  In  six  there  was  spasm  of  the  neck  of  the  blad- 
der, accompanied  with  severe  pain,  and  causing  great  difficulty  of  uri- 
nating, in  one  there  was  incontinence  of  urine,  in  five  pain  in  the  ute- 
rus and  ovaries,  and  in  one  neuralgia  of  the  rectum. 

Motility  was  affected  in  eight  cases.  In  four  of  these  there  were 
strong  tonic  contractions  of  the  muscles  of  the  lower  extremities,  and 
in  four  paralysis.  In  all  of  these  there  were  occasional  clonic  spasms 
simulating  chorea.  Of  the  nineteen  cases  in  which  there  was  also 
dorsal  tenderness,  the  symptoms  were  in  general  those  characteristic 
of  spinal  irritation  of  both  regions. 

d.  The  whole  spine  was  tender  in  fifteen  cases,  and  so  extensive  was 
the  hyperesthesia  that  it  was  scarcely  possible  to  press  upon  the  most 
limited  spot  without  producing  pain.  Of  these  cases  the  most  promi- 
nent symptom  in  three  was  epilepsy,  in  one  paralysis,  sometimes  of 
the  upper  and  sometimes  of  the  lower  extremities,  and  in  three  con- 
tractions of  the  limbs.  Neuralgic  pains,  either  in  the  scalp,  face, 
neck,  chest,  upper  extremities,  abdomen,  and  lower  extremities,  were 
present  in  every  case,  according  to  the  part  most  severely  affected 
for  the  time  being.  The  heart  was  disordered  in  five  cases,  the 
stomacli  in  ten,  in  three  there  was  difficulty  of  swallowing,  from 
alternating  paralysis,  and  spasm  of  the  muscles  of  the  larynx,  and 
in  two  aphonia. 

Causes. — The  most  powerful  predisposing  cause  is  sex.  Of  the  one 
hundred  and  fifty-six  cases,  one  hundred  and  forty  were  females.  Age 
is  likewise  influential  in  determining  to  the  disorder.  Of  one  hundred 
and  thirty-seven  cases  in  which  I  have  recorded  the  age,  seventy-two 
were  between  fifteen  and  twenty-five,  thirty-two  between  twenty-five 
and  thirty-five,  fifteen  under  fifteen,  and  eighteen  over  thirty-five.  The 
period  of  life  between  fifteen  and  twenty-five  is  therefore  that  at  which 
spinal  irritation  is  most  apt  to  occur. 

Hereditary  influence  was  ascertained  to  exist  in  thirty  eases. 

The  exciting  cause  of  spinal  irritation  is  not  always  easy  to  ascer- 
tain. In  thirty  out  of  one  hundred  and  thirty-seven  cases  I  could  not, 
by  the  most  careful  inquiry,  find  any  circumstance  likely  to  have  given 
it  origin.  In  twenty-one  it  was  manifestly  produced  by  blows,  falls,  or 
strains,  in  twelve  it  was  obviously  caused  by  Bexual  excesses,  and  four 


388  DISEASES   OF  TIIE   SITNAL   CORD. 

by  onanism.  In  ten  there  was  reason  to  ascribe  it  to  anxiet)r  and  grief, 
in  two  to  excessive  mental  exertion,  in  twenty-one  to  insufficient  phys- 
ical exercise,  in  fourteen  to  innutritious  and  insufficient  food,  in  three 
to  over-indulgence  in  alcoholic  liquors,  and  in  one  to  the  use  of  opium. 
In  the  remaining  nineteen  cases  it  followed  exhausting  diseases,  such 
as  typhoid,  scarlet,  and  intermittent  fever,  dysentery,  and  diphtheria, 
and  was  probably  directly  the  result  of  their  influence. 

Abnormal  positions  of  the  uterus  and  prolonged  irritation  of  the 
ovaries  sometimes  occur  in  spinal  irritation. 

It  may  also  be  caused  by  obliteration  of -the  aorta  or  spinal  vessels, 
by  tumors,  thrombosis,  or  embolism,  by  haemorrhage  from  vessels  in  re- 
lation with  those  of  the  cord,  or  by  exposure  to  severe  cold. 
•»     In  general  terms,  it  may  be  said  that  any  cause  capable  of  reducing 
the  powers  of  the  system  may  produce  spinal  irritation. 

Morbid  Anatomy  and  Pathology. — I  have  already  stated  it  as  my 
opinion  that  the  essential  condition  of  spinal  irritation  is  anasmia  of  the 
posterior  columns  of  the  cord.  Other  writers  have  ascribed  it  to  in- 
flammation, congestion,  hysteria,  and  numerous  other  factors.  The 
reasons  which  have  induced  me  to  arrive  at  this  conclusion  are  briefly 
as  follows  :  Owing  to  the  fact  that  spinal  irritation  is  not  per  se  a  fatal 
disease,  we  rarely  have  the  opportunity  to  verify  any  views  we  may 
hold  in  regard  to  its  pathology.  In  the  few  cases  in  which  post-mortem 
examinations  were  made,  nothing  abnormal  was  found,  a  circumstance, 
however,  far  more  compatible  with  the  idea  I  have  expressed  than  with 
any  other  : 

1.  It  is  a  well-recognized  fact  that  irritation  is  often  a  result  of  a 
deficient  supply  or  a  poor  quality  of  blood.  Thus  headaches  are  fre- 
quently caused  by  cerebral  anaemia,  and  are  promptly  relieved  by  in- 
creasing the  amount  of  blood  in  the  cerebral  blood-vessels.  Irritability 
of  the  mind  is  also  a  constant  accompaniment.  A  feebly-nourished 
stomach  rejects  food,  and  is  the  seat  of  pain.  An  anaemic  heart  beats 
with  great  rapidity,  weak  muscles  are  affected  with  tremor,  and  an  ex- 
hausted generative  system  is  brought  into  a  state  of  unnatural  erethism 
by  the  slightest  kind  of  excitation.  Analogy,  therefore,  supports  the 
theory  I  have  suggested. 

2.  The  diagnosis  of  diseases  of  the  spinal  cord  has  become  so  perfect 
that  we  are  able  to  distinguish  congestion,  meningitis,  myelitis,  soften- 
ing, tumors,  etc.,  by  their  symptoms  and  by  the  means  of  research  at 
our  command.  We  see,  therefore,  that  the  morbid  phenomena  which 
result  from  such  conditions  are  not  such  as  we  now  class  under  the  head 
of  spinal  irritation.  This  division  of  the  subject  will  be  more  fully  con- 
sidered under  the  head  of  diagnosis. 

3.  I  have  repeatedly  ascertained,  by  actual  experience,  that  those 
agents  which  are  known  to  diminish  the  amount  of  blood  in  the  spinal 
vessels  invariably  increase  the  severity  of  the  symptoms  due  to  spinal 


SPINAL  ANJ2MIA.  389 

irritation,  while  they  are  as  effectually  lessened  in  intensity  by  remedies 
which  tend  to  produce  spinal  hyperaemia. 

4.  The  general  condition  of  patients  the  subjects  of  spinal  irritation 
is  always  below  par,  and  the  exciting  causes  are  all  such  as  tend  to  the 
production  of  asthenia. 

5.  The  character  of  the  symptoms  points  decidedly  to  the  greater, 
and  at  times  sole  implication  of  the  posterior  columns.  There  are  cases 
of  the  disorder  in  which  there  is  no  derangement  of  motility  in  any  part 
of  the  body,  and  in  all  cases  aberrations  of  sensibility  are  the  prominent 
features.  Moreover,  the  viscera  are  generally  affected  in  their  func- 
tions, a  circumstance  of  itself  strongly  indicative  of  the  situation  of  the 
lesion  in  the  posterior  columns. 

These  circumstances,  I  think,  go  very  far  toward  confirming  the 
view  I  have  expressed,  that  in  spinal  irritation  the  vessels  of  the  cord, 
especially  those  of  the  posterior  columns,  contain  less  blood,  and  that 
this  fluid  is  inferior  in  quality  to  that  of  the  organ  when  it  is  in  a 
healthy  condition.  Now  that  the  function  of  the  sympathetic  nerve,  as 
regards  its  action  in  regulating  the  calibre  of  the  blood-vessels,  is  so 
satisfactorily  proven,  we  can  partially  understand  how  local  congestions 
and  anaemias  may  be  superinduced.  It  is  probable,  therefore,  that  the 
original  disturbance  in  many  cases  of  spinal  irritation  resides  in  the 
sympathetic  system,  and  the  intimate  anatomical  relations  existing  be- 
tween the  two  nervous  centres  are  strongly  in  favor  of  this  suggestion. 

On  the  other  hand,  many  of  the  phenomena  of  spinal  irritation  point 
strongly  to  the  secondary  involvement  of  the  sympathetic  system.  It 
is  thus  that  the  visceral  disturbances  which  form  such  prominent  feat- 
ures are  mainly  to  be  explained. 

The  pathology  of  several  others  of  the  more  striking  symptoms  of 
spinal  irritation  has  been  a  subject  of  frequent  discussion,  but  at  the 
present  day  presents  no  difficulties.  Thus  the  excitation  of  pain  in  the 
tissues  to  which  the  cutaneous  nerves  are  distributed  results  from  the 
law  that  irritation  at  a  nervous  centre  induces  pain  at  the  points  in 
which  the  nerves  arising  from  that  centre  end.  Each  compound  spinal 
nerve  sends  a  twig  to  the  skin  contiguous  to  it,  and  these  twigs  termi- 
nate immediately  over  the  spinous  processes.  Now,  whenever  an  irrita- 
tion is  thus  transmitted  to  the  periphery,  it  may  be  reflected  back  to  the 
centre  whence  it  oama,  by  local  irritations.  Thus  a  patient  is  suffering 
from  chronic  inflammation  of  the  spinal  cord,  and  in  consequence  has 
pain  and  muscular  spasms  in  his  lower  extremities.  An  irritation  ap- 
plied directly  to  the  cord  increases  the  pain  and  spasms;  an  irritation 
applied  to  the  lower  extremities  augments  the  pain  in  the  cord,  and 

may  induce  pain  and  spasms  in  distant  parts  of  the  body.  Hepceitis 
that  pressure  on  the  skin  over  the  spinous  processes  not  only  causes 
cutaneous  pain,  but  al  rise  to  spinal  pain,  and  neuralgia  sensa- 

tions in  lie  se  nerves  which  come  from  the  irritated  pari  of  the  cord. 


390  DISEASES  OF  THE  SPINAL   CORD. 

The  pain  existing  in  the  cord  is  aggravated  by  percussion  or  mus- 
cular action.  The  spinal  cord,  it  is  true,  is  inclosed  in  a  strong  and 
thick,  bony  canal,  which,  however,  is  entirely  filled  by  its  contents.  A 
blow,  therefore,  on  the  exterior  of  the  column  causes  a  vibration,  which 
is  propagated  through  the  bony  structure  to  the  cord  and  its  mem- 
branes. If  this  blow  be  very  violent,  the  concussion  may  be  such  as  to 
inflict  irreparable  damage  on  the  cord.  When  any  portion  of  the  cord 
is  in  a  state  of  irritation,  a  very  light  blow  upon  the  spinous  processes, 
over  the  disordered  part,  will  cause  severe  pain,  or  notably  add  to  that 
already  present.  The  vertebral  column  is  flexible,  and  therefore  mus- 
cular action  may,  by  producing  deviations  from  the  ordinary  line  fol- 
lowed, occasion  pressure,  and,  in  the  abnormal  condition  of  the  cord, 
excite  pain. 

Diagnosis. — Recollecting  that  no  case  is  to  be  regarded  as  one  of 
spinal  irritation  which  is  not  characterized  by  spinal  tenderness,  we 
have  our  diagnostic  inquiries  limited  to  the  distinguishing  of  spinal 
irritation  from  other  spinal  affections.  It  is  certainly  true  that  the 
distinction  has  often  been  overlooked,  and  that  at  times  there  is  a  real 
difficulty  in  forming  a  correct  judgment.  Nevertheless,  by  carefully 
estimating  all  the  circumstances,  permanent  errors  of  diagnosis  are  not 
likely  to  occur. 

There  are  three  diseases  of  the  spinal  cord  which  may  in  their  ear- 
lier stages  be  confounded  with  simple  spinal  irritation.  These  are 
chronic  myelitis,  meningitis,  and  congestion.  As  the  treatment  of  these 
affections  is  in  many  respects  the  exact  reverse  of  that  proper  for  spinal 
irritation,  and  as  they  are  of  far  more  serious  character,  it  is  important 
to  make  as  early  and  as  correct  a  discrimination  as  possible. 

In  both  spinal  irritation  and  myelitis  there  is  tenderness  over  some 
part  of  the  vertebral  column,  which  tenderness  is  increased  by  pressure, 
but  this  tenderness  is  never  due  to  hyperesthesia  of  the  skin,  whereas 
in  spinal  irritation  it  often  is. 

In  spinal  irritation  there  is  never,  so  far  as  my  experience  goes, 
anaesthesia,  whereas  this  is  a  constant  accompaniment  of  myelitis. 

The  contractions  which  take  place  in  some  cases  of  spinal  irritation 
are  painless,  while  those  due  to  myelitis  are  attended  with  great  suffer- 
ing. 

In  myelitis  there  is  a  sensation  as  if  a  tight  cord  were  tied  around 
the  body  at  the  upper  limit  of  the  paralysis,  a  sensation  which  is  absent 
in  spinal  irritation.  It  is  true  that  Mr.  Teale  has  described  several 
cases  which  he  classed  as  spinal  irritation  and  in  which  the  sensation  of 
constriction  was  present,  but  careful  examination  of  the  histories  leaves 
scarcely  a  doubt  that  these  were  really  cases  of  myelitis. 

The  bladder  is  never  paralyzed  in  spinal  irritation,  whereas  in  mye- 
litis it  generally  is,  if  the  inflammation  be  located  in  the  lower  dorsal 
region  of  the  cord.     The  same  is  true  of  the  sphincter  ani.     Myelitis  is 


SPINAL   ANEMIA.  391 

always  productive  of  paralysis,  and  there  is  always  more  or  less  atrophy 
of  the  paralyzed  muscles.  Spinal  irritation  seldom  gives  rise  to  paraly- 
sis, which,  when  it  does  result,  is  always  incomplete,  and  is  never  pro- 
ductive of  atrophy. 

The  progress  of  myelitis  is  generally,  unless  arrested  by  appropriate 
treatment,  toward  a  worse  condition,  whereas  no  such  tendency  is 
manifested  by  spinal  irritation. 

In  myelitis,  after  the. first  ten  days,  electrical  "reactions  of  degen- 
eration" can  always  be  obtained  in  paralyzed  muscles,  while  in  spinal 
irritation  the  reactions  are  normal. 

From  spinal  meningitis,  spinal  irritation  is  distinguished  by  the  cir- 
cumstances that  in  the  former  disease  there  are  constant  painful  spasms 
of  the  muscles  of  the  back,  pain  La  the  cord,  and  no  spinal  tenderness 
increased  by  pressure.    . 

From  congestion  of  the  spinal  cord  and  its  membranes,  spinal  irri- 
tation is  sufficiently  distinguished  by  the  facts  that  there  is  generally 
little  or  no  pain  in  the  cord  in  the  first-named  affection,  and  no  spinal 
tenderness.  In  congestion,  likewise,  the  paralysis  and  other  symptoms 
are  always  worse  after  the  patient  has  been  lying  down,  while  in  spinal 
irritation  the  recumbent  position  always  alleviates  the  condition. 

Another  means,  which  in  doubtful  cases  will  invariably  lead  to  a 
correct  diagnosis,  is  afforded  by  the  known  effects  of  certain  medicines. 
Thus  spinal  irritation  is,  as  I  have  several  times  ascertained,  made 
worse  by  the  administration  of  ergot,  while  each  one  of  the  other  dis- 
eases I  have  named  is  alleviated.  The  reverse  is  true  of  strychnia, 
which  in  all  cases  aggravates  the  symptoms  of  myelitis,  meningitis, 
or  congestion,  while  it  is  an  efficient  means  of  cure  in  spinal  irrita- 
tion. An  hypodermic  injection  of  the  thirtieth  of  a  grain  is  suffi- 
cient to  settle  the  matter  in  cases  where  the  diagnosis  is  of  difficult 
formation. 

The  flatulence,  eructations,  and  vomiting,  are  very  symptomatic 
of  spinal  irritation,  while  they  are  rarely  phenomena  of  either  of  the 
other  affections. 

One  other  disease  is  liable  to  be  confounded  with  spinal  irritation, 
and  that  is  angular  curvature,  in  which  there  is  spinal  tenderness  in- 
creased l>y  pressure.  The  facts,  however,  that  strumous  disease  of  the 
Vertebrae  generally  occurs  in  children,  that  tin'  scrofulous  diathesis  is 
always  present,  that  an  angular  prominence  can  be  detected  by  careful 
examination,  that  the  paralysis  progressively  becomes  more  profound, 
that  the  constitutional  effects  are  more  Bevere,  are  sufficient,  even  in 
doubtful  cas<  9,  to  guide  to  a  correcl  diagnosis. 

Prognosis. — The  prognosis  in  cases  of  spinal  irritation  is  generally 
favorable.  In  fact,  so  far  as  my  experience  extends,  I  ha1  e  ne\  er  seen 
a  case  which  entirely  resisted  treatment, and  very  leu  in  which  a  cure 
ivas  not  ultimately  effected.     Winn  remedies  suitable  for  the  difficulty 


392  DISEASES   OF   THE   SPINAL   CORD. 

do  not  prove  successful,  it  is  because  the  patient  does  not  steadfastly 
persevere  in  their  use.  Of  the  one  hundred  and  fifty-six  cases  form- 
ing the  basis  of  this  chapter,  one  hundred  and  thirty-three  were 
thoroughly  cured,  ten  were  lost  sight  of  soon  after  treatment  was 
commenced,  but  were  materially  improved,  and  thirteen  were  relieved 
for  the  time  being,  but  continued  to  have  relapses. 

Treatment. — The  principles  of  treatment  applicable  to  spinal  irrita- 
tion are  four  :  1.  To  remove  the  cause.  2.  To  improve  the  general 
tone  of  the  system.  3.  To  increase  the  amount  of  blood  in  the  spinal 
cord,  and  improve  the  nutrition  of  this  organ.  4.  To  set  up  a  counter- 
irritant  action  in  the  vicinity  of  the  disordered  region  of  the  cord. 

In  regard  to  the  first  indication,  I  have  nothing  special  to  say.  The 
cause  once  ascertained,  common-sense  would  dictate  its  removal  as 
speedily  and  as  effectually  as  possible,  by  the  proper  means  according 
to  its  character. 

The  second  indication  is  to  be  met  by  tonics,  such  as  quinine  and 
iron,  and  especially  stimulants  judiciously  administered.  I  am  as  well 
convinced  of  the  general  applicability  of  alcohol  in  some  form,  in  the 
treatment  of  spinal  irritation,  as  I  am  of  any  thing.  Whiskey,  brandy, 
and  rum,  are  to  be  preferred  on  account  of  their  less  liability  to  dis- 
agree with  the  stomach,  and  as  containing  a  greater  percentage  of 
alcohol  than  vinous  or  malt  liquors.  Among  the  tonics  the  prepara- 
tions of  zinc  are  valuable,  and  I  think  the  oxide  is  to  be  preferred. 
Cod-liver  oil  is  also  of  great  service. 

The  third  indication  is  easily  fulfilled  by  strychnia,  phosphorus,  phos- 
phoric acid,  and  opium.  The  two  first-named  remedies  may  be  very 
satisfactorily  combined  in  a  pill  containing  half  a  grain  of  extract  of 
nux-vomica  and  the  tenth  of  a  grain  of  the  phosphide  of  zinc,  which 
may  be  given  three  times  a  day.  Strychnia  may  also  be  given  by  solu- 
tion of  the  sulphate  in  dilute  phosphoric  acid,  and  in  doses  of  about  the 
thirty-second  of  a  grain  to  half  a  drachm  of  the  acid.  The  beneficial 
effects  of  these  remedies  are  perceived  in  a  few  days.  Opium  is  espe- 
cially useful  in  those  cases  in  which  there  are  contractions  of  the  limbs, 
and  here  its  action  is,  of  course,  not  solely  that  of  an  agent  increasing 
the  amount  of  blood  in  the  cord.  I  prefer  to  give  it  either  in  the  form 
of  suppositories,  composed  each  of  half  a  grain  of  the  aqueous  extract 
and  a  sufficient  quantity  of  the  butter  of  cacao,  or  by  hypodermic  injec- 
tion of  morphia.  I  have  frequently  seen  contractions,  which  had  per- 
sisted with  obstinacy  for  several  weeks,  relax  in  a  few  minutes  under  the 
influence  of  opium  thus  administered. 

The  application  of  hot  water  to  the  spine  is  also  an  admirable  adju- 
vant. It  should  be  used  as  hot  as  can  be  borne.  Nothing  is  better  for 
the  purpose  than  Dr.  Chapman's  India-rubber  bags. 

The  fourth  indication  is  one  of  great  importance,  and,  when  properly 
carried  into  effect,  a  cure  will  often  result  in  slight  cases  without  any 


SPIXAL   AX.EMIA.  393 

other  means  of  treatment  being  employed.  Of  counter-irritants  my 
experience  leads  me  decidedly  to  the  employment  of  blisters  in  prefer- 
ence to  any  others.  They  should  be  applied  to  the  skin,  immediately 
over  the  painful  part  of  the  spine,  and  should  be  renewed  as  often  as 
may  be  necessary.  Dry  cups  almost  always  do  good.  Leeches,  or  any 
other  means  for  the  abstraction  of  blood,  are,  according  to  my  experi- 
ence, always  prejudicial. 

Electricity,  in  whatever  form  it  may  be  applied  to  the  skin,  acts 
only  as  a  counter-irritant.  It  certainly  has  great  power  in  the  dis- 
ease under  consideration.  A  seance  should  be  given  every  day,  and 
should  not  last  longer  than  ten  or  fifteen  minutes.  In  every  way 
the  statical  form  is  to  be  preferred.  The  patient  should  be  seated  on 
the  insulated  stool,  and  then  sparks  should  be  drawn  with  the  lar^e 
brass  ball-electrode  from  the  part  of  the  skin  in  which  the  morbid  con- 
dition exists.  The  clothing  should  not  be  removed.  It  often  happens 
that  all  spinal  tenderness  disappears  after  two  or  three  applications. 
If  the  galvanic  or  faradaic  current  be  employed,  the  electrodes — wet 
sponges  or  wire  brushes — should  be  drawn  slowly  over  the  skin  of  the 
affected  part,  and  the  current  should  be  strong  enough  in  either  case 
to  redden  the  skin  and  to  cause  considerable  pain. 

Latterly  I  have  made  use  of  percussion  with  decided  beneficial 
results.  A  stick  somewhat  like  a  crochet-needle  is  run  through  an 
India-rubber  ball  about  two  inches  in  diameter,  and  with  this  instru- 
ment the  skin  is  pounded  for  five  minutes  or  so  night  and  morning. 
The  painful  parts  should  not  be  spared.  Tolerance  is  generally  estab- 
lished in  a  few  days,  and  then  the  patient  takes  pleasure  in  the  pounding. 

Besides  these  therapeutical  means,  there  are  others  of  a  more  strictly 
hygienic  character,  which  cannot  be  overlooked.  Thus  the  food  should 
be  pf  a  highly-nutritious  character,  moderate  physical  exercise  should 
be  taken,  and  as  much  time  as  possible  should  be  spent  in  the  open  air. 

Patients  almost  always  feel  more  comfortable  in  the  recumbent  po- 
sition than  any  other,  because  thereby  the  blood  is  allowed  to  settle  in 
the  spinal  vessels.  They  should  not  therefore  be  prevented  lying  down 
during  the  greater  part  of  the  day,  but  at  the  same  time  they  should  be 
encouraged  to  take  exercise,  and  especially  so  when  there  is  any  loss 
of  power  in  the  lower  extremities.  The  induced  or  faradaic  current  is 
almost  always  of  service,  when  applied  to  the  affected  muscles,  and  the 
direct  is  of  great  efficacy  when  passed  through  neuralgic  nervous  trunks. 

In  illustration  of  the  views  inculcated  in  this  ohapter,  1  append  (he 
following  details  of  cases  : 

Case  I.  Irritation  of  the  Cervical  Region  of  the  Spinal  Cord. — 
Mrs.  J.  S.  consulted  me,  May  7,  1868,  for  what  she  had  been  informed 
was  a  cerebral  disorder.     The  patienl  was  thirty-eighl  years  of  age,  had 
had  five  children,  and  had  always  enjoyed  good  health  (ill  fcwoy< 
previously,  when  she  had  been  thrown  from  her  carriage.     She  was  not 


394  DISEASES   OF   THE   SPINAL   CORD. 

stunned  or  otherwise  seriously  injured.  Soon  after  the  accident  she 
noticed  a  rumbling  noise  in  one  ear,  and  in  a  few  days  subsequently  the 
other  ear  became  similarly  affected.  About  the  same  time  there  were 
flashes  of  light  before  the  eyes,  and  a  dull,  heavy  pain  in  this  point  of 
the  head.  Vertigo  was  also  frequently  present.  There  was  insomnia, 
and  when  she  did  sleep  she  was  very  apt  to  be  attacked  with  night- 
mare. 

These  symptoms  continued  to  annoy  her  for  several  months,  with- 
out, however,  compelling  her  to  seek  for  medical  advice,  until  at  last 
she  had  a  seizure  which  Avas  certainly  epileptic  in  its  character.  This  was 
followed  with  disturbance  of  vision,  and  intense  neuralgia  of  the  fifth 
pair  of  nerves.  She  now  placed  herself  under  the  charge  of  a  physician 
in  a  neighboring  city,  where  she  was  then  residing,  who  diagnosticated 
a  tumor  of  the  brain,  and  gave  an  unfavorable  opinion  as  to  the  ulti- 
mate result.  He,  however,  advised  the  use  of  iodide  of  potassium. 
She  took  this  in  large  doses  faithfully  for  three  months — during  which 
period  she  had  two  more  epileptic  attacks — without  perceiving  any  ben- 
efit, and  then  she  went  to  Europe.  While  there  she  consulted  a  num- 
ber of  physicians  and  surgeons  of  eminence,  all  of  whom  gave  a  very 
guarded  prognosis.  By  the  advice  of  several  of  these  she  took  the 
bromide  of  potassium,  with,  at  first,  some  advantage,  but  this  was  event- 
ually lost,  and  her  symptoms  became  as  severe  as  before.  She  had 
several  epileptic  paroxysms  during  the  four  months  she  was  taking  the 
bromide.  Finally,  she  traveled  through  G  3rmany  and  Italy,  and,  still 
obtaining  no  relief,  returned  home.  I  saw  her  a  few  days  after  her 
arrival.  She  was  then  suffering  from  facial  neuralgia,  excessive  tender- 
ness of  the  scalp,  so  that  she  could  not  have  her  hair  brushed  without 
enduring  great  pain,  obscureness  of  vision,  pain  in  the  eyeballs,  redness 
of  the  conjunctiva?,  vertigo  almost  constantly,  great  mental  irritability, 
amounting  at  times  to  positive  insanity  ;  wakefulness,  nightmare,  and 
contraction  of  the  fingers,  the  nails  being  stroDgly  pressed  against  the 
palm  of  the  hand. 

Ophthalmoscopic  examination  showed  dilatation  of  the  retinal  ves- 
sels, arterial  and  venous  pulsation,  and  congestion  of  the  optic  disks 
of  both  eyes. '   The  pupils  of  both  eyes  were  contracted. 

Perhaps  I  should  not  have  suspected  any  spinal  disorder,  if  she  had 
not  herself  called  my  attention  to  a  pain  which  she  said  she  constantly 
felt  between  the  shoulders.  I  therefore  examined  the  upper  part  of 
the  spine  very  carefully,  and  found  deep-seated  pain  developed  by  per- 
cussion over  the  seventh  cervical  vertebra,  and  great  hyperesthesia  of 
the  skin  in  the  same  region.  Her  symptoms  were  not  those  in  the  least 
indicative  of  congestion  of  the  cord  or  its  membranes,  of  meningitis,  or 
myelitis,  and  the  apparent  severity  of  the  cerebral  symptoms,  and  the 
general  good  condition  of  her  mind  and  sensorial  and  motor  functions, 
were  so  incompatible,  that  I  could  not,  upon  reflection,  bring  myself  to 


SPINAL    ANEMIA.  395 

the  belief  that  she  was  affected  with  any  organic  disease  of  the  brain. 
My  inquiries  and  examinations  all  led  me  to  the  conclusion  that  she  was 
laboring  under  spinal  irritation  of  the  lower  cervical  region. 

I  therefore  prescribed  for  her  five  drops  of  the  phosphorated  oil 
three  times  a  day,  applied  a  blister  to  the  painful  spot,  and  daily 
passed  the  direct  galvanic  current  through  the  cord,  by  applying  the 
negative  pole  to  the  fifth  cervical,  and  the  positive  to  the  sixth  dorsal. 
My  object  was,  not  only  to  improve  the  nutrition  of  the  cord,  but  also, 
by  irritation  of  the  sympathetic,  to  contract  the  vessels  of  the  brain. 
Budge  and  Waller  had  shown,  several  years  previously,  that,  when  that 
portion  of  the  spinal  cord  situated  between  the  seventh  cervical  and 
sixth  dorsal  vertebrae  is  acted  upon  by  the  galvanic  current,  the  pupils 
are  dilated.  Now,  dilatation  of  the  pupils  is  produced  by  excitation  of 
the  sympathetic,  and  excitation  of  the  sympathetic,  within  the  limits 
mentioned,  likewise  causes  contraction  of  the  vessels  of  the  brain,  as 
can  readily  be  seen  by  ophthalmoscopic  examination  while  the  current 
is  passing. 

Under  the  influence  of  this  treatment  the  amendment  was  rapid, 
and  at  the  end  of  three  months  she  was  entirely  cured.  It  was  neces- 
sary, however,  to  apply  eleven  blisters. 

Case  II.  Irritation  of  the  Cervical  Region  of  the  Cord. — M.  S.,  a 
gentleman  of  sedentary  habits,  consulted  me,  August,  1867,  for  intense 
headache  and  facial  neuralgia,  with  which  he  had  suffered  for  several 
months.  The  disease  had  come  on  gradually,  and,  although  now  never 
entirely  absent,  was  paroxysmal  in  its  character,  being  more  severe  at 
night  than  through  the  day.  The  external  pain  followed  the  course  of 
the  fifth  pair  of  nerves  through  all  its  branches  ;  the  internal  was  fixed 
in  the  posterior  part  of  the  head,  and  was  evidently  due  to  cerebral 
anaemia,  as  it  was  relieved  by  stimulants  and  by  holding  the  head  in  a  de- 
pendent position.  Vertigo  was  frequently  present,  and  the  disposition  to 
sleep  was  excessive,  though,  owing  to  the  pain,  it  could  not  be  indulged 
in  for  more  than  a  few  minutes  at  a  time.  Nausea  was  occasionally  a 
symptom,  but  never  to  the  extent  of  being  followed  by  vomiting. 

On  examining  the  spine  of  this  gentleman,  I  found  tenderness  over 
the  fourth  and  seventh  cervical  vertebrae.  Two  blisters  were  at  once 
applied,  and  Aiiken's  syrup  of  the  phosphate  of  iron,  quinine,  and 
strychnia,  administered.  From  the  first,  improvement  was  manifested, 
and  in  less  than  a  month  the  cure  was  complete. 

III.  Irritation  of  the  Dorsal  Region  of  the  Spinal  Cord. — 
Mra.  .1.  I'...  aged  twenty-four,  oontralted  me,  March,  1868,  for  obstinate 
vomiting,  and  neuralgia  pains  in  tin'  left  breast.  Sin-  was  thin,  pale, 
and  anaemic,  and  had  Buffered  for  over  a  year.  She  also  complained  of 
a  dull,  aching  pain  in  the  middle  of  the  back,  whiob  was  increased  by 
even  moderate  physical  exercise.     The  vomiting  took  pi  larly 

after  cyny  meal,  and  even  wat«  r  was  at  once  thrown  up.     She  waa 


396  DISEASES  OF  THE  SPINAL  CORD. 

under  the  impression  that  the  disorder  was  the  result  of  exposure  for 
several  hours  to  very  severe  cold  while  in  an  open  boat. 

Recognizing1,  at  once,  the  fact  that  the  main  difficulty  lay  in  the 
cord,  I  carefully  examined  the  whole  spine,  and  found  excessive  tender- 
ness over  the  spinous  processes  of  the  sixth,  seventh,  and  eighth  dorsal 
vertebrae.  There  was  also  deep-seated  spinal  pain  developed  by  percus- 
sion. 

I  ordered  the  application  of  a  blister,  and  the  internal  use  of  small 
quantities,  frequently  repeated,  of  milk-punch  (one  ounce  of  brandy  to 
three  of  milk).  The  first  wineglassful  was  at  once  rejected,  and  so 
was  a  tablespoonful  which  she  took  half  an  hour  subsequently.  I  then 
reduced  the  quantity  to  a  teaspoonful  every  half -hour.  This  was  re- 
tained, and  was  the  first  nutriment  of  any  kind  which,  for  nearly  eleven 
months,  had  not  been  rejected  wholly  or  in  part. 

The  next  day  I  found  that  the  blister  had  drawn  well,  and  that  the 
nausea  and  vomiting  were  greatly  diminished,  as  were  likewise  the 
neuralgic  pains.  A  teaspoonful  of  the  following  mixture  was  then 
directed  to  be  taken  three  times  a  day,  immediately  after  meals  :  IJ. 
Strychnine  sulph.,  gr.  j;  ferri  pyrophosph.,  quinioe  sulph.,  aa  3  ss  ;  acid, 
phosph.  dil.,  syrupi  zingiberis,  aa  |  ij.  M.  ft.  mist.  The  milk-punch 
was  still  continued,  but,  in  treble  the  dose,  less  frequently  given. 

Gradually  all  the  symptoms  decreased  in  violence,  and  at  the  end  of 
two  weeks  she  was  enabled  to  retain  a  moderate  quantity  of  food  at 
each  meal.  Any  excess  was  still,  however,  followed  by  vomiting.  She 
had  increased  five  pounds  in  weight,  and  was  greatly  improved  in  per- 
sonal appearance. 

In  two  months  she  had  gained  twenty-one  pounds,  and  was  as  well 
as  she  had  ever  been  in  her  life.  The  spinal  tenderness  had  entirely 
disappeared  ;  seven  blisters  were  applied  in  all. 

Case  IV.  Irritation  of  the  Dorsal  Region  of  the  Spinal  Cord. — 
Mrs.  W.  had  for  more  than  three  years  suffered  from  spasmodic  move- 
ments of  the  upper  extremities,  not  distinguishable  from  those  of  true 
chorea,  which  occasionally  were  followed  by  contractions  of  the  flexors 
of  the  wrists  and  fingers.  There  were  also  infra-mammary  pain,  eructa- 
tions, and  vomiting.  When  she  came  under  my  care,  June  22,  1869, 
she  was  reduced  to  almost  a  skeleton,  and  was  suffering,  in  addition  to 
the  symptoms  above  mentioned,  from  acute  pain  in  the  back.  This 
pain  she  informed  me  had  not  been  ordinarily  very  severe,  but  was, 
nevertheless,  constantly  present.  On  examination  I  found  tenderness 
over  the  first,  second,  and  third  dorsal  vertebras.  I  at  once  applied  the 
constant  galvanic  current  in  a  manner  already  described,  and  continued 
it  for  five  minutes,  with  the  effect  of  mitigating  the  pain  in  the  spine 
and  the  nausea.  The  ensuing  day  I  repeated  the  application,  and  in 
addition  prescribed  the  mixture  given  in  Case  III.  She  retained  it  on 
her  stomach,  as  she  did  the  food  which  she  ate  that  day.     Brandy  in 


SPINAL   ANAEMIA.  397 

ounce-doses  was  given  with  her  lunch  and  dinner.  The  galvanism  was 
continued  daily  for  eighteen  days,  at  the  end  of  which  time  she  was  free 
from  pain,  from  the  spasms,  and  from  the  vomiting.  Her  appearance 
was  immensely  improved,  and  she  had  increased  seven  pounds  in  weight. 
The  galvanism  was  now  discontinued,  but  the  strychnia  mixture  and 
the  brandy  were  persevered  with  for  over  a  month  longer.  She  was  then 
well. 

Case  V.  Irritation  of  the  Lumbar  Region  of  the  Spinal  Cord. — 
E.  T.,  an  unmarried  lady,  aged  twenty-nine,  consulted  me,  August,  18G9, 
for  paralysis  of  the  lower  extremities,  attended  with  spinal  tenderness 
and  abdominal  pains.  She  had  been  treated  for  inflammation  of  the 
spinal  cord,  had  been  cupped,  leeched,  and  had  had  an  issue  made  over 
the  seat  of  the  pain. 

When  I  first  saw  her  she  was  unable  to  walk,  having  been  in  this 
condition  for  several  months.  As  she  sat  in  her  chair,  she  could  readi- 
ly move  her  legs  in  any  desired  direction,  but  to  bear  her  weight  upon 
them  was  an  utter  impossibility.  There  was  no  alteration  of  sensibility. 
Her  general  appearance  was  not  anaemic,  nor  was  she  in  the  least  degree 
hysterical.  Upon  careful  examination,  I  was  unable  to  find  any  reason 
to  induce  the  belief  that  she  was  laboring  under  spinal  congestion, 
meningitis,  or  myelitis,  or  that  there  was  softening  of,  or  pressure  upon, 
the  cord.  I,  however,  discovered  great  tenderness  over  the  first  and 
second  lumbar  vertebras,  and  found  that  strong  pressure  in  this  region 
induced  deep-seated  spinal  pain  and  sharp  neuralgic  sensations  along 
the  course  of  the  crural  nerves. 

Regarding  the  case  as  one  of  pure  spinal  irritation,  I  applied  the 
constant  galvanic  current  to  the  back  every  alternate  day,  and  adminis- 
tered the  following  prescription  :  I£.  Zinci  phosphidi,  gr.  iij  ;  ext.  nucis 
vom.,  gr.  xv.  M.  ft.  in  pil.  no.  xxx.  Dose,  one  three  times  a  day.  I 
likewise  directed  the  application,  to  the  painful  part  of  the  spine,  of 
flannel,  wrung  out  of  spirits  of  turpentine,  to  be  continued  daily  till 
redness  and  decided  smarting  were  produced.  A  full  and  nutritious 
diet,  with  ale,  was  enjoined.  Under  this  treatment  she  improved  so 
rapidly  in  every  respect  that  in  twenty-three  days  she  was  able  to  walk 
with  a  cane,  and  in  a  few  days  more  than  a  month  was  well,  being  in  as 
good  health,  according  to  her  own  report,  as  she  had  ever  enjoyed  in 
her  life. 

Ajsuaax  OF  THE  antero-lateual  columns  of  the  cokd. 

The  phenomena  which  in  my  opinion  arc  the  result  of  an  amende 
condition  of  tin-  and  ro-lateral  columns  of  the  Bpinal  cord  have  hitherto 
been  olassed  under  the  heads  of  spinal  paresis,  functional  paralysis, 
reflex  paralysis,  inhibitory  paralysis,  paralysis  from  peripheral  irritation, 
etc.  Several  of  these  names  are  applied  with  reference  to  the  causes, 
others  with  reference  to  the  symptoms,  but  none  to  the  lesion. 


398  DISEASES  OF  THE   SPINAL   CORD. 

Symptoms. — The  most  prominent  symptom  of  anaemia  of  the  ante- 
rolateral columns  of  the  spinal  cord  is  paralysis  of  motion  in  those 
parts  of  the  body  which  derive  their  nerves  from  the  affected  portion 
of  the  cord,  and  in  many  cases  of  those  below  the  seat  of  the  lesion. 
This  paralysis  is  incomplete,  the  patient,  if  the  lower  extremities  are 
affected,  being  able  to  walk,  though  he  does  so  with  difficulty.  It  is 
noticed,  too,  that  some  muscles  are  more  apt  to  be  paralyzed  than 
others,  the  tibialis  anticus  and  the  peroneal  group  rarely  escaping. 

In  the  great  majority  of  cases  the  paralysis  is  confined  to  the  lower 
extremities,  constituting  paraplegia.  The  -reason  for  this  is,  that  the 
anaemic  condition  of  the  cord  which  causes  the  paralysis  is  more  fre- 
quently excited  by  irritatien  transmitted  from  the  genito-urinary  and 
digestive  organs  than  from  any  others. 

Spasmodic  contractions  of  the  paralyzed  muscles  are  not  often  met 
with,  though  occasionally  there  are  slight  twitchings,  fibrillary  in  their 
character. 

It  is  rarely  the  case  that  the  paralysis  extends,  as  it  does  in  that 
which  results  from  congestion  of  the  cord.  The  affection  usually  super- 
venes suddenly,  and  is  about  as  severe  in  the  beginning  as  at  any  sub- 
sequent period. 

The  bladder  and  rectum  are  very  rarely  involved  as  a  consequence 
of  the  spinal  lesion,  though  disease  of  either  of  these  organs  often 
causes  anaemia  of  the  antero-lateral  columns  of  the  cord.  In  a  few 
cases,  however,  I  have  witnessed  both  paralysis  of  the  bladder  and  of 
the  sphincter  coming  on  late  in  the  course  of  the  disease,  and  evidently 
dependent  on  it. 

Electro-muscular  irritability  is  rarely  impaired.  Reflex  excitability 
is  also  generally  unaffected.  In  the  worst  cases,  tickling  the  sole  of 
the  foot  will  cause  the  leg  to  be  drawn  up,  even  against  the  volition  of 
the  patient. 

Disorders  of  sensibility  are  not  prominent  features  in  anaemia  of  the 
antero-lateral  columns  of  the  spinal  cord.  Locally  there  is  very  rarely 
pain,  and  in  the  paralyzed  parts  there  is  neither  anaesthesia,  hyperes- 
thesia, nor  abnormal  sensations  of  any  kind.  There  is  never,  in  the  un- 
complicated affection,  the  sensation  of  constriction  about  any  part  of 
the  body.  The  stomach  and  bowels  are  not  often  affected,  unless  there 
is  at  the  same  time  some  degree  of  anaemia  of  the  posterior  columns. 
But  in  one  very  interesting  case,  occurring  in  a  lady  of  this  city,  and 
produced  by  exposure  to  extreme  cold  while  crossing  to  Governor's 
Island  in  an  open  boat,  there  were  vomiting  every  time  food  was  taken 
into  the  stomach,  and  the  most  obstinate  constipation  I  have  ever  wit- 
nessed. It  very  frequently  happened  that  this  lady  had  no  operation 
from  her  bowels  for  over  a  month. 

Causes. — Anaemia  of  the  antero-lateral  columns  of  the  spinal  cord 
may  be  produced  by  any  cause  capable  of  interrupting  the  flow  of  blood 


SPINAL  AN.EMIA.  399 

to  the  region  in  question,  of  lessening  the  calibre  of  its  autocthonous 
arteries,  or  of  so  lowering  the  quality  of  the  blood  as  to  unfit  it  for  the 
purposes  of  nutrition. 

Thus  it  may  be  caused — though  not  without  the  implication  of  the 
posterior  columns — by  abdominal  tumors  compressing  the  aorta,  or  by 
disease  of  this  vessel,  leading  to  partial  or  complete  obliteration  ;  by 
thrombosis  or  embolism  of  the  spinal  arteries  ;  or  by  direct  loss  of  blood 
from  vessels  supplying  the  cord,  or  deriving  their  blood  from  the  spinal 
vessels. 

The  calibre  of  the  intra-spinal  vessels  may  be  lessened  through  the 
influence  of  extreme  cold,  and  anaemia  of  the  antero-lateral  columns 
thus  be  induced.  Several  cases  of  this  kind  have  come  under  my  care,  in 
which  paraplegia  has  supervened  suddenly  during  or  after  exposure  to 
very  low  temperature,  especially  when  combined  with  a  moist  state  of 
the  atmosphere.  Lying  on  damp  ground  has  caused  it  in  a  number  of 
instances. 

It  not  unfrequently  follows  exhausting  diseases  of  various  kinds.  I 
have  known  it  to  supervene  on  dysentery,  diarrhoea,  cholera,  typhoid 
fever,  typhus,  diphtheria,  and  several  other  affections. 

But  the  most  common  cause  of  the  disorder  is  undoubtedly  periph- 
eral irritation,  and  this  is  very  frequently  an  affection  of  the  genito- 
urinary organs.  My  friend  Dr.  S.  Weir  Mitchell  l  has  written  very  ex- 
haustively on  this  subject,  and  has  shown  the  relation  which  exists 
between  the  different  paralyses  now  usually  called  reflex,  and  injuries 
of  nerves.  Under  the  head  of  pathology  I  shall  have  occasion  to  return 
to  Dr.  Mitchell's  valuable  contributions. 

Diagnosis. — Anaemia  of  the  antero-lateral  columns  of  the  cord  is  dis- 
tinguished from  congestion  by  the  facts  that  the  symptoms  are  miti- 
gated by  the  recumbent  position  instead  of  being  increased  in  violence, 
as  in  the  latter  affection  ;  that  the  paralysis  shows  no  tendency  to  be- 
come more  severe,  and  that,  when  the  bladder  or  rectum  is  involved, 
the  derangement  of  either  viscus  precedes  the  paralysis. 

From  anaemia  of  the  posterior  columns,  it  is  diagnosticated  by  the 
fact  that  the  more  obvious  symptoms  are  related  to  motility,  sensibility 
not  being  involved,  while  in  the  former  the  reverse  is  the  case. 

The  diagnosis  from  myelitis  will  be  pointed  out  when  inflammation 
of  the  cord  is  under  consideration. 

Prognosis. — The  probability  of  a  favorable  termination  is  great.  In 
fact,  no  affection  of  the  cord  is  so  susceptible  of  cure  when  there  is  no 
mechanical  obstruction  in  the  aorta  or  spinal  arteries.  But  this  opin- 
ion is  expressed  with  the  understanding  that  the  cause  must  first  be 

•  Circular  No.  6, 1864,  Surgeon-General's  Office.  "Reflex  Paralysis,"  by  Drs,  Mitch- 
ell, Iforehouse,  and  Keen.  Also  "  Wounds  and  Injuries  of  Nerves  by  the  same,"  Phil- 
adelphia, 1864.  Also  "Paralysis  from  Peripheral  Irritation,"  by  Dr.  Mitchell,  Nine  York 
iMical  Journal,  February,  18R6. 


400  DISEASES  OF  THE  SPINAL  CORD. 

removed.  So  long  as  this  continues  in  action,  anaemia  cf  the  antero- 
lateral columns  of  the  cord  is  a  very  obstinate  affection.  When  the  arte- 
ries are  obstructed,  then,  as  in  the  brain  under  like  conditions,  softening 
of  the  cord  may  take  place. 

Morbid  Anatomy  and  Pathology. — Post-mortem  examination,  of  per- 
sons who  have  suffered  with  symptoms  indicative  of  what  I  consider  to 
be  anaemia  of  the  antero-lateral  columns  of  the  cord,  does  not  reveal  the 
existence  of  any  material  spinal  lesion.  The  reason  for  this  is,  that  anae- 
mia of  the  cord  is,  in  the  nature  of  things,  a  very  difficult  disease  to 
detect,  and  cannot  be  definitely  made  out,  unless  the  capillaries  are 
measured  under  the  microscope. 

But  it  is  this  ver}r  absence  of  obvious  lesions  which  indicates  very 
positively  the  existence  of  anaemia,  and  the  character  of  the  symptoms 
shows  that  the  antero-lateral  columns  are  its  seat. 

Several  varieties  of  paralysis  result  from  anaemia  of  the  antero-lat- 
eral columns.  Classing  these  as  Mitchell  '  has  done,  from  their  apparent 
causes,  we  find  that  there  are — 

1.  Paralyses  arising  during  disease  of  the  genito-urinary  organs. 

2.  Those  which  occur  during  or  just  after  dysenteries,  diarrhoeas, 
super-purgation,-  or  in  connection  with  worms. 

3.  Such  as  arise  during  or  after  pneumonia  or  pleurisy. 

4.  Such  as  are  seemingly  brought  on  by  dentition. 

5.  The  paralysis  of  diphtheria,  fevers,  and  eruptive  disorders. 

6.  Such  as  seems  to  be  occasioned  by  cold,  or  by  cold  and  moisture. 

7.  Paralysis  due  to  external  injury. 
To  this  list  may  be  added — 

8.  Paralysis  resulting  from  certain  medicines  and  drugs. 

9.  Paralysis  due  to  great  emotional  disturbance. 

Many  cases  of  each  of  these  varieties  of  paralysis  have  come  under 
mv  notice,  and  there  are  few  medical  practitioners  who  have  not  wit- 
nessed instances  referable  to  one  or  more  of  the  foregoing  categories. 
The  principal  theories  of  their  immediate  cause  are — 

1.  That  of  Mr.  Stanley,2  by  which  certain  varieties  of  paralysis  are 
attributed  to  the  transmissal  of  an  irritation  from  a  diseased  organ  to 
the  spinal  cord,  whence  it  is  reflected  to  the  muscles  as  paralysis. 

This  is  no  explanation  at  all,  and  leaves  the  condition  of  the  cord 
out  of  consideration.  There  is  no  proof  whatever  that  an  irritation  can, 
without  causing  change  in  the  structure  of  the  nervous  centre,  induce 
either  paralysis  of  motion  or  of  sensation. 

2.  That  of  Dr.  Brown-Sequard,8  which    ascribes  the    affections    in 
1  "  Paralysis  from  Peripheral  Irritation,  with  Reports  of  Cases,"  New  York  Medical 

Journal,  February,  1866,  p.  323. 

*  "  On  Irritation  of  the  Spinal  Cord  and  its  Nerves  in  Connection  with  Disease  of  the 
Kidneys,"  "  Medico-Chirurgical  Transactions,"  vol.  xviii.,  p.  2G0. 

'  Lectures  on  the  "  Diagnosis  and  Treatment  of  the  Principal  Forms  of  Paralysis  of 
the  Lower  Extremities,"  Philadelphia,  1861. 


SPINAL  ANEMIA.  401 

question  to  a  lesion  of  the  cord,  consisting  in  a  spasm  of  the  spinal 
vessels  by  which  their  calibre  is  diminished.  This  spasm  is,  according 
to  this  eminent  neurologist,  the  result  of  a  peripheral  irritation  trans- 
mitted through  the  nerves  coming  from  a  diseased  organ  or  part  of  the 
body,  to  the  vaso-motor  nerves  of  the  portion  of  the  cord  giving  origin 
to  these  nerves. 

This  was,  so  far  as  I  have  been  able  to  ascertain,  the  first  attempt 
to  designate  the  character  of  the  lesion,  which,  as  will  be  at  once  per- 
ceived, is  anaemia.  That  anaemia  can  be  induced  by  peripheral  irritation 
is,  I  think,  well  established.  But  though  this  theory  accounts  for  many 
cases  of  spinal  paralysis,  such  as  are  now  under  notice,  it  will  not  em- 
brace all,  for  we  may  have  anaemia  and  consequent  loss  of  motor  power 
resulting  from  other  causes  than  irritation.  Moreover,  Dr.  Brown- 
Sequard  did  not  fix  the  lesion  in  the  antero-lateral  columns,  nor  associ- 
ate the  symptoms  with  any  derangement  in  the  structure  of  this  region 
of  the  cord. 

3.  Dr.  Mitchell,  in  the  paper  to  which  I  have  already  referred,  divides 
the  several  kinds  of  paralysis  mentioned  into  three  classes:  those  which 
are  asserted  to  be  due  to  disease  of  the  genito-urinary  system,  a  cause 
which  he  denies  in  toto  /  those  which  are  said  to  be  produced  by  periph- 
eral irritation  of  the  intestinal  canal,  an  influence  which  he  also  in  great 
part  denies;  and  those  which  follow  wounds  and  injuries  of  nerves. 

Dr.  Mitchell  rejects  altogether  the  reflex  theory  of  Dr.  Brown- 
Sequard,  and  says: 

"  If  I  were  now  to  sum  up  the  probabilities  in  the  way  of  causation 
of  palsies  peripherally  induced,  I  should  be  disposed  to  refer  some  cases 
to  exhaustion  from  too  constant  or  excessive  exercise  of  normal  func- 
tions, and  others  to  irritation  from  disease  or  injury,  and  to  consequent 
exhaustion  of  the  centres;  while,  as  regards  the  intervention  of  vascular 
agency,  I  should  reject  the  idea  of  prolonged  vasal  spasm?  and  consider 
it  possible  that  in  some  instances  over-excitation  might  result  in  dila- 
tation of  the  vessels,  in  which  case  some  material  lesion  would  surely 
result  if  the  condition  in  question  were  of  long  continuance." 

While  not  prepared  to  accept  Dr.  Mitchell's  views  in  their  entirety, 
they  are,  in  my  opinion,  perfectly  in  accordance  with  the  doctrine  of 
anaemia  of  the  antero-lateral  columns.  As  to  whether  this  anaemia  is 
the  result  of  spasm  of  the  spinal  vessels,  or  exhaustion,  is  a  question 
which,  for  the  present  at  least,  is  not  definitely  settled.  My  own  opin- 
ion is  thai  paralyses  of  apparently  peripheral  origin  arc  referable  to 
anaemia,  produced  in  some  cases  by  vaso-motor  spasm,  and  in  others  by 
nervous  exhaustion. 

TIm-  experiments  of  Kllssmaul  and  Tenner1  arc  perfectly  conclusive 
as  to  the  effects  of  cutting  off  the  supply  of  blood  to  the  spinal  cord. 

1  "The  Nature  and  Origin  <>f  Epileptiform  Convulsion*  oanaed  by  Profuse  Bleeding 
etc."     Nefc  Sydenham  Society  TYiuishitions,  London,  1859,  p.  53,  et  seg. 


402  DISEASES   OF  THE   SPINAL   CORD. 

These  observers  compressed  the  aorta  in  rabbits  so  completely  that  not 
a  drop  of  blood  could  reach  the  spinal  cord  below  the  point  of  occlusion. 
The  consequence  was,  that  there  was  complete  paralysis  of  all  the  mus- 
cles receiving  their  nervous  influence  from  the  anaemic  portion  of  the 
cord.  The  possibility,  therefore,  of  spinal  anaemia  producing  paralysis, 
is  beyond  doubt.  In  these  experiments,  however,  the  blood  was  of 
course  shut  off  from  both  the  anterior  and  posterior  columns,  and  there- 
fore the  phenomena  were  not  those  of  simple  motor  paralysis. 

M.  Vulpian '  has  recently  discussed,  very  thoroughly,  the  several 
questions  connected  with  the  pathology  of  reflex  paralysis.  By  an 
experiment,  which  consisted  in  faradizing  a  communicating  branch  of 
the  intra-thoracic  chain  of  ganglia,  a  decided  contraction  was  seen  to 
take  place  in  the  vessels  of  the  spinal  cord  at  the  point  of  origin  of  the 
intercostal  nerve  in  relation  with  the  irritated  branch.  When  the 
faradization  was  intermitted,  the  vessels  returned  to  their  former  size — 
or,  perhaps,  even  became  a  little  larger  than  was  natural.  This  experi- 
ment was  therefore  followed  by  a  result  similar  to  that  recorded  by 
Brown-Sequard,  who  says : a  "  A  contraction  of  blood-vessels  in  the  spinal 
cord  I  have  seen  (in  the  vessels  of  the  pia  mater)  take  place  under  my 
eyes,  when  a  tightened  ligature  was  applied  on  the  hilus  of  the  kidney, 
irritating  the  renal  nerves,  or  when  a  similar  operation  was  performed 
on  the  blood-vessels  and  nerves  of  the  suprarenal  capsules.  Generally 
in  these  cases  the  contraction  is  much  more  evident  on  the  side  of  the 
cord  corresponding  with  the  side  of  the  irritated  nerves,  which  fact  is 
in  harmony  with  another  and  not  rare  one,  observed  first  by  Combaire 
(as  regards  the  kidney),  and  often  seen  by  me  after  the  extirpation  of 
one  kidney,  or  one  suprarenal  capsule — i.  e.,  paralysis  of  the  corre- 
sponding lower  limb." 

M.  Vulpian  admits  that  anaemia  of  the  spinal  cord  causes  with 
great  rapidity  the  abolition  of  the  medullary  functions.  The  fact  is 
established  by  experiments  consisting  in  the  obliteration  of  the  spinal 
vessels  by  substances  injected  into  them.  Thus  Flourens,3  many  years 
ago,  injected  the  powder  of  lycopodium  into  the  crural  artery  of  a  dog, 
taking  care  to  throw  the  substance  with  some  force  into  the  artery 
against  the  current  of  the  circulation,  so  that  it  entered  the  abdominal 
aorta  and  was  distributed  to  the  spinal  vessels.  The  powder  occluded  the 
more  minute  of  the  arteries,  and  a  localized  anaemia  of  the  spinal  cord 
was  thus  produced.  The  result  was,  that  the  posterior  extremities  of 
the  animal  were  almost  immediately  paralyzed. 

Feltz*  injected  finely-powdered  charcoal  into  the  right  crural  artery 

1  "Le9ons  sur  l'appareil  vaso-moteur,"  etc.,  Paris,  1875,  tome  ii.,  p.  48,  et  seq. 
J  "  Lectures  on  the  Diagnosis  and  Treatment  of  the  Principal  Forms  of  Paralysis  of 
the  Lower  Extremities,"  Philadelphia,  1861,  p.  24. 

'  "  Comptes  rendus  de  l'Academie  des  Sciences,"  1847,  p.  905. 

*  "Traite  clinique  ct  experimental  des  embolics  capillaires,"  Paris,  1870,  p.  186. 


SPINAL  ANEMIA.  403 

of  a  dog,  so  that  the  injection  passed  into  the  inferior  part  of  the  ab- 
dominal aorta.  The  animal  was  at  once  paralyzed  in  the  right  posterior 
extremity,  and  shortly  afterward,  in  the  corresponding  limb  of  the 
opposite  side.  After  death,  particles  of  the  powder  were  found  in  the 
spinal  arteries. 

Vulpian1  has  several  times  repeated  these  experiments,  using  the 
powder  of  lycopodium,  and  has  invariably  found  the  animals  become 
almost  instantly  paraplegic. 

Nevertheless,  he  is  not  sure  that  the  paralyses,  called  reflex,  are  the 
result  of  spinal  anaemia;  on  the  contrary,  he  doubts  if,  in  reality,  there 
are  any  such  affections.  He  is  disposed  to  think  that  they  are  to  be 
classed  in  several  categories  ;  one  embracing  cases  in  which  there  is  a 
definite  lesion  of  the  cord  ;  another,  those  cases  which  occur  in  hyster- 
ical, hypochondriacal,  and  epileptic  persons,  from  irritations  existing  in 
distant  parts  of  the  body,  and  which  he  calls  paralyses  of  peripheral 
origin  ;  and  a  third,  comprehending  all  instances  which  cannot  be  in- 
cluded in  either  of  these  classes,  and  especially  embracing  the  cases  due 
to  the  action  of  cold  on  the  surface  of  the  body. 

M.  Vulpian's  chief  objection  to  the  theory  of  spinal  anaemia  is  that, 
when  the  arteries  are  occluded  by  artificial  emboli,  softening  of  the  cord 
takes  place.  This  is  doubtless  true  in  the  majority  of  cases,  but  cer- 
tainly not  in  all,  for  in  the  dog,  which  was  the  subject  of  Feltz's  experi- 
ment, life  was  prolonged  for  two  days,  and  it  is  expressly  stated  that 
the  cord  was  not  softened.  Moreover,  in  the  anaemia  produced  by 
peripheral  irritations  the  vessels  are  not  entirely  closed.  Their  calibre 
is  simply  diminished  ;  some  blood  reaches  the  cord,  but  this  is  not 
sufficient  for  the  full  performance  of  its  functions.  If  softening  were 
the  invariable  result  of  a  lessened  supply  of  blood  to  an  organ,  we 
should  meet  with  it  constantly  in  cases  of  general  cerebral  anaemia  from 
any  one  of  the  many  causes  capable  of  producing  that  condition. 

Now,  I  have  repeatedly  performed  Flourens's  experiment,  both  with 
powdered  lycopodium  and  charcoal,  and  have  never  failed  to  obtain 
paralysis  of  the  posterior  extremities.  It  is  true  the  loss  of  power  was 
permanent,  remaining  in  each  case  during  the  life  of  the  animal,  but 
such  a  result  is,  of  course,  to  be  expected,  for  it  is  impossible  to  get  rid 
of  the  substances  occluding  the  vessels.  In  the  anaemia  produced  by 
reflex  irritation  or  spinal  exhaustion,  the  possibility  of  removing  the 
cause,  overcoming  the  vaso-motor  spasm,  or  improving  the  nutrition  of 
the  cord,  places  the  condition  entirely  in  a  different  line  from  that  due 
to  meohanical  occlusion  of  the  vessels,  except  as  regards  the  one  point 
<>f  anaemia,  and  even  lure  the  difference  is  great,  for  in  the  former  the 
supply  of  blood  is  merely  lessened,  while  in  the  latter  it  is  cut  off 
altogether. 

In  practice  wo  often  find  thai  the  anaemia  is  not  restricted  to  eithei 

1  Op.  cit.,  p,  53. 


404  DISEASES  OF  THE  SPINAL   CORD. 

set  of  columns,  and  that  the  symptoms  are  accordingly  those  of  motor 
paralysis,  aberrations  of  sensibility,  and  functional  disturbances  in  va- 
rious organs,  such  as  we  have  just  considered  as  being  caused  by 
anaemia  of  the  posterior  columns. 

Treatment. — The  treatment  is  similar  in  general  features  to  that  ap- 
plicable to  anaemia  of  the  posterior  columns  already  considered,  though 
there  is  not  the  same  benefit  to  be  derived  from  counter-irritation.  The 
indications,  therefore,  are  to  remove  the  cause,  to  improve  the  general 
tone  of  the  system,  and  to  increase  the  amount  of  blood  in  the  spinal 
vessels. 

So  far  as  the  first  indication  is  concerned,  it  very  often  happens  that 
its  fulfillment  is  sufficient  for  the  entire  removal  of  the  anaemia,  and  the 
disappearance  of  the  consequent  paralysis.  This  is  especially  the  case 
as  regards  those  instances  which  are  due  to  peripheral  irritations  of  va- 
rious kinds.  Within  the  last  few  days  a  young  lady,  aged  twelve,  was 
brought  to  me  by  her  mother  to  be  treated  for  paraplegia,  which  had 
developed  very  suddenly.  There  was  no  evidence  of  serious  organic 
difficulty,  and  no  apparent  cause  of  peripheral  irritation.  Her  symp- 
toms, however,  all  pointed  to  anaemia  of  the  antero-lateral  columns,  and, 
on  the  principle  of  exclusion,  I  thought  it  probable  there  might  be 
worms  in  the  alimentary  canal.  I  therefore  administered  several  doses 
of  santonine,  followed  by  castor-oil.  A  number  of  lumbrici  were  dis- 
charged, and  the  paralysis  disappeared  in  the  night  as  suddenly  as  it 
had  arisen. 

In  another  case,  a  gentleman  was  rendered  paraplegic  soon  after 
contracting1  a  catarrhal  inflammation  of  the  bladder.  The  bladder  affec- 
tion  was  disregarded  by  his  physician,  and  energetic  means  were  used 
against  the  paralysis,  but  without  effect.  I  suggested  the  expediency 
of  suspending  the  administration  of  the  strychnia  and  the  application 
of  counter-irritants  to  the  spine,  and  directing  attention  to  the  cure  of 
the  disorder  of  the  bladder.  This  was  done,  and,  at  the  same  rate  as 
the  inflammation  yielded  to  the  treatment,  the  paraplegia  disappeared. 

The  general  tone  of  the  system  is  to  be  improved  by  such  measures 
as  were  recommended  for  the  accomplishment  of  the  same  end  in  anae- 
mia of  the  posterior  columns. 

For  fulfilling  the  third  indication,  strychnia  and  phosphorus  are  pref- 
erable to  any  other  internal  remedies.  I  usually  prescribe  them  together 
in  doses  of  the  tenth  of  a  grain  of  the  phosphide  of  zinc,  with  from  a 
third  to  a  half  a  grain  of  the  extract  of  nux-vomica  in  pill,  to  be  taken 
three  times  a  day.  Lately,  however,  I  have  pursued  the  practice  of  giv- 
ing the  strychnia  in  gradually-increasing  doses  till  there  is  evidence  of 
its  characteristic  physiological  effects  being  produced.  Two  grains  of 
the  sulphate  of  strychnia  are  to  be  dissolved  in  an  ounce  of  water,  and 
ten  minims,  containing  one  twenty-fourth  of  a  grain  of  strychnia,  given 
three  times  a  day  ;  the  next  day  eleven  minims  are  administered  for 


SPDJAL  AXJEMIA.  405 

each  dose,  the  next  twelve,  and  so  on  till,  as  often  happens,  the  paraly- 
sis yields,  or  till  the  reflex  excitability  of  the  legs  is  increased,  or  stiff- 
ness of  their  muscles  or  those  of  the  nucha  is  induced.  In  either  of 
these  latter  events  the  administration  must  be  stopped  for  a  day,  and 
then  the  original  dose  of  ten  minims  be  given  and  increased  as  before. 
There  is,  according  to  my  experience,  no  medication  so  effectual  in  all 
those  forms  of  paralysis  called  reflex,  inhibitory,  functional,  etc.,  and 
which,  in  my  opinion,  result  from  anaemia  of  the  antero-lateral  columns 
of  the  cord,  as  this  with  strychnia.  It  requires  care  and  prudence,  and, 
if  these  qualities  be  exercised,  is  perfectly  safe.  It  very  generally  hap- 
pens that,  before  the  patient  reaches  thirty  minims  (one-eighth  of  a 
grain)  for  a  dose,  the  paralysis  begins  to  yield.  In  one  case,  however, 
due  to  exposure  to  severe  cold,  I  was  obliged  to  carry  the  dose  to  sixty 
minims — equal  to  one-fourth  of  a  grain  of  strychnia — before  the  excita- 
bility of  the  cord  was  increased,  or  any  signs  of  the  paralysis  yielding 
were  observed.  The  patient  recovered  after  taking  three-quarters  of  a 
grain  of  strychnia  daily  for  over  two  weeks. 

In  a  very  remarkable  case  recently  under  my  care,  sent  to  me  by 
Dr.  Brooks,  of  Cleveland,  the  paralysis  following  diphtheria  affected 
both  arms  and  both  legs,  and  was  evidently  increasing  daily  in  inten- 
sity. At  last,  the  patient  could  scarcely  move  a  muscle  of  either  ex- 
tremity, and  was,  of  course,  unable  to  walk.  Strychnia  was  adminis- 
tered according  to  the  manner  above  described,  and  also  by  hypodermic 
injections.  Amendment  was  slow  but  steady,  and  I  sent  him  home, 
where,  under  Dr.  Brooks's  care,  who  boldly  carried  out  the  treatment, 
he  entirely  recovered.  At  no  time,  while  under  my  observation,  was 
there  any  evidence  of  strychnization,  although  large  doses  of  the 
remedy,  amounting  at  one  time  to  a  grain  a  day,  were  given.  The  irri- 
tability of  the  cord  appeared  to  be  entirely  abolished.  Neither  the 
bladder  nor  rectum  was  paralyzed,  and  cutaneous  sensibility  was  scarce- 
ly impaired. 

The  only  local  application  which  is  decidedly  beneficial  in  anaemia 
of  the  antero-lateral  columns  is  the  constant  galvanic  current,  which 
should  be  used  in  the  manner  recommended  for  anaemia  of  the  poste- 
rior columns. 

As  regards  the  paralyzed  muscles,  the  induced  or  faradaic  current  is 
useful  in  keeping  them  exercised,  and  thus  preserving  their  nutrition. 
Friction  and  kneading  exercise  a  like  olTect. 

In  those  cases  of  Bpinal  anaemia  due  to  obstruction  of  the  aorta,  or 
occlusion  of  spinal  vessels  by  emboli,  no  specific  treatment  is  of  any 
avail. 


406  DISEASES   OF   THE   SPINAL   CORD. 

CHAPTER  III. 

SPINAL  HEMORRHAGE— SPINAL  MENINGEAL  HAEMORRHAGE. 

These  two  conditions  having  a  common  cause,  being  often  associ- 
ated, and  having  a  general  resemblance  to  each  other,  may  properly  be 
considered  together. 

Symptoms. — A  haemorrhage  into  the  substance  of  the  spinal  cord  is 
characterized  hy  pain  at  the  seat  of  the  lesion,  and  by  derangements 
of  sensibility  and  of  the  power  of  motion  in  all  those  parts  of  the  body 
below.  These  consist  of  ana3Sthesia  and  loss  of  motility,  but  occasion- 
ally there  are  hyperesthesia  and  spasms.  In  the  majority  of  cases  the 
bladder  and  its  sphincter  and  the  sphincter  ani  are  also  paralyzed.  Ob- 
stinate priapism  is  an  occasional  symptom.  Reflex  excitability  and 
electro-muscular  contractility  are  soon  impaired  or  altogether  lost. 

An  elevation  of  temperature  is  said '  to  take  place  in  the  paralyzed 
parts,  and  the  formation  of  sloughs  on  the  sacrum  and  other  parts  ex- 
posed to  pressure  is  a  frequent  occurrence.  In  a  case  under  my  own 
observation,  a  man  fell  from  a  scaffold  and  struck  the  small  of  his 
back  against  a  projecting  beam.  He  was  taken  up  paraplegic,  and 
within  six  hours  three  large  sloughs — one  over  the  sacrum  and  one  over 
each  hip — made  their  appearance.  Sensibility  was  entirely  abolished  in 
the  paralyzed  limbs.  The  bladder  and  rectum  were  completely  para- 
lyzed, and  death  ensued  on  the  fifth  day.  Post-mortem  examination 
discovered  a  clot  in  the  substance  of  the  cord,  extending  from  the  tenth 
dorsal  to  the  fifth  lumbar  vertebra,  and  involving  both  the  white  and 
the  gray  substance.     There  was  neither  fracture  nor  luxation. 

Hemorrhage  into  the  substance  of  the  cord  may  be  either  rapidly 
or  slowly  developed.  In  the  former  case  it  generally  terminates  fatally 
in  a  few  days  or  even  hours  ;  in  the  latter,  life  may  be  prolonged  for 
several  months,  or  may  be  preserved,  with  more  or  less  paralysis  of 
motion  or  sensibility,  or,  as  is  generally  the  case,  of  both  in  the  parts 
below  the  seat  of  the  lesion. 

If  the  seat  of  the  hemorrhage  be  high  up  in  the  neck,  death  is 
almost  instantaneous  from  the  paralysis  of  the  phrenic  nerve. 

When  the  lesion  is  meningeal,  the  symptoms  are  not  generally  so 
rapidly  developed  as  when  it  is  situated  in  the  substance  of  the  cord. 
The  pain  is  greater,  and  there  is  a  more  decided  tendency  to  spasmodic 
jerkings  in  the  limbs  receiving  their  nerves  from  the  part  of  the  cord 
below  the  extravasation.  Occasionally  the  convulsive  movements  are 
general,  and,  according  to  Ilayem,  are  more  marked  in  the  paralyzed 
than  in  the  non-paralyzed  limbs.  Hyperesthesia  may  alternate  with 
anesthesia,  or  this  latter  may  alone  be  present. 

1  Ilayem,  "Des  h^morrhagies  mtra-rachidiennes,"  Paris,  1872,  p.  186. 


SPINAL  HEMORRHAGE.  407 

The  extent  of  motor  paralysis  is  very  variable,  both  as  regards  in- 
tensity and  diffusion.  Sometimes  all  the  muscles  below  the  seat  of  the 
lesion  are  more  or  less  paralyzed  ;  at  others,  some  muscles  altogether 
escape.  I  have  a  patient  under  treatment  who  has,  in  consequence  of 
a  spinal  haemorrhage,  probably  meningeal,  lost  sensation  in  a  small 
region  of  skin  over  the  glutei  muscles,  and  sensation  and  motion  in  all 
the  tissues  below  both  knees.  Sensation  and  motion  are  intact  in  all 
other  parts  of  the  lower  extremities.  The  bladder  is  unaffected,  but 
there  is  very  obstinate  constipation. 

Reflex  excitability  is  often  exaggerated,  and  the  electro-muscular 
contractility  increased  in  the  early  stage  ;  but,  if  the  patient  survives 
the  immediate  effects  of  the  lesion,  both  these  faculties  become  im- 
paired, or  abolished  altogether.  If  the  patient  survives  the  injury,  he 
remains  paralyzed  to  a  degree  corresponding  to  the  extent  of  the 
injury  to  the  spinal  cord.  In  severe  cases  there  will  be  complete 
paraplegia  with  anaesthesia  from  the  lesion  downward,  all  reflex  ex- 
citability will  be  abolished,  and  atrophy  of  the  paralyzed  muscles  soon 
begins,  and  progresses,  until  all  or  nearly  all  of  the  muscular  tissue 
has  disappeared.  Meningeal  haemorrhage  taking  place  above  the  third 
cervical  vertebra  may  be  speedily  fatal,  from  the  interruption  to  res- 
piration due  to  paralysis  of  the  phrenic  nerve. 

Causes. — Spinal  haemorrhage,  either  in  the  substance  of  the  cord  or 
of  the  membi-anes,  is  generally  the  result  of  injury.  Thus  it  may  be 
caused  by  blows  on  the  vertebral  column,  by  falls,  or  by  gunshot,  or 
by  wounds  with  penetrating  instruments.  It  may  also  be  produced  by 
tetanus  and  by  the  rupture  of  aneurisms,  but  is  in  either  of  these  cases 
meningeal.  Excessive  fatigue,  the  suppression  of  the  menstrual  flow, 
undue  venereal  indulgence,  alcoholism,  yello\y  fever,  typhoid  fever, 
disease  of  the  vertebrae,  and  the  toxic  influence  of  strychnia,  have  also 
been  alleged  as  causes.  In  many  cases  not  traumatic  the  immediate 
cause  is  not  known.  The  male  sex  appears  to  be  much  more  liable 
than  the  female.  Of  nineteen  eases  of  haemorrhage  into  the  substance 
of  the  cord  analyzed  by  Gintrac,1  fifteen  were  in  males. 

Diagnosis. — The  diagnosis  must  mainly  be  determined  by  the  his- 
tory of  the  case,  and  by  the  facts  that  the  symptoms  come  <>n  suddenly 
ami  advance  rapidly.  Often  there  are  greal  difficulties  experienced  in 
arriving  at.  a  satisfactory  opinion  relative  to  the  diagnosis,  and  I 
quote  the  following  case  not  only  because  <>f  its  interest,  but  because 
it  illustrates  the  scientific  acumen  of  a  distinguished  member  of 
the  medical   profession.     Under  the  designation  of  "case  of  spinal 

apoplexy,"  Dr.  Robert  Jackson1  says: 

1  "  Trait  »'•  thtorique  et  pratique  dea  maladies  dc  l'apparcil  nerveux,"  Paris,  1869, 
tome  ii.,  p.  423. 

-  Quoted  in  Qua rierly  Journal of  FtycKotogieal  Medicine  and  Medical  Jurisprud 

New  York,  1809,  vol.  Hi.,  p.  810,  from  the  Lancet, 


408  DISEASES  OF  THE  SPINAL  CORD. 

"  On  Sunday,  May  2,  1869,  Miss  F.  L.,  a  bright,  merry,  healthy, 
and  well-developed  young  lady,  aged  fourteen,  arose  as  usual,  but  while 
dressing  said  '  her  fingers  felt  weak.'  She,  however,  went  to  church, 
both  morning  and  evening,  and  seemed  quite  well. 

"  On  Monday,  she  again  got  up  as  usual,  but  complained  of  the  same 
'weak  feeling '  in  her  hands.  Otherwise,  she  felt  very  well;  participated 
in  the  usual  studies  of  the  day;  and  in  the  evening  had  a  warm  bath, 
enjoyed  it,  and  got  into  it  '  with  the  use  of  all  her  limbs.' 

"On  Tuesday  she  was  much  the  same;  ate  a  good  breakfast,  feed- 
ing herself,  etc.  During  the  forenoon,  however,  the  weak  feeling  con- 
siderably increased,  and  I  was  sent  for.  I  found  her  lying  on  her  back 
in  bed,  quite  merry,  laughing,  free  from  all  pain,  and  rather  amused, 
than  otherwise,  at  her  condition.  She  was,  however,  unable  to  shake 
hands  with  me,  or  to  move  her  arms,  except  at  the  wrists  ;  and  failed 
altogether  to  pick  up  a  pin  placed  on  a  book  before  her. 

"  On  Wednesday,  there  was  no  material  alteration.  I  observed, 
however,  that  the  intercostal  muscles  were  not  acting  quite  freely  ;  she 
seemed,  too,  to  lie  heavier  in  her  bed,  and  she  evidently  was  now  unable 
to  turn  herself  round.  There  was  also  a  moist  crepitant  rdle  over  all 
the  chest,  with  a  little  cough.  The  secretions  continued  free,  the  pulse 
regular;  and  she  ate,  being  fed,  a  good  dinner  of  roast-beef. 

"  On  Thursday,  Sir  William  Jenner  kindly  saw  her  with  me.  Her 
general  condition  was  not  greatly  altered  ;  every  sensation  perfect ;  no 
anaesthesia  ;  and  she  displayed  her  usual  quick  perception  and  intelli- 
gence. A  careful  examination,  however,  at  this  time,  clearly  demon- 
strated a  great  and  decided  loss  of  power  in  all  the  voluntary  muscles 
of  respiration,  and  in  those  muscles  of  the  arms,  back,  and  chest,  sup- 
plied by  the  branches  of  the  cervical  nerves.  The  diaphragm,  too,  was 
becoming  fixed,  and  there  was  slight  lividity  about  the  cheeks,  with  a 
fall  of  the  natural  temperature. 

"From  these  symptoms,  it  became  evident  that  there  was  some 
serious  spinal  lesion,  implicating  probably,  and  more  particularly,  the 
anterior  branches  of  the  cervical  nerves,  and  the  origin  of  the  phrenics. 
Sir  William  Jenner  diagnosed,  and,  as  will  be  seen,  with  perfect  accu- 
racy, a  clot  in  the  cervical  portion  of  the  spinal  cord,  and  he  prognosed, 
notwithstanding  the  bright  life  and  still  merry  laugh,  a  speedy  and 
fatal  result.  This  took  place  thirty  hours  afterward,  without  pain, 
without  loss  of  consciousness  or  sensation,  but  only  as  the  cessation  of 
the  power  of  respiration  became  more  and  more  determined,  with  a 
desire  to  be  raised  '  higher  and  higher.' 

"  In  this  interesting  case  a  post-mortem  examination  was  kindly 
allowed,  and  made  forty  hours  after  death.  There  was  slight  opacity 
of  the  dura  mater  in  several  places.  Brain  congested  and  soft.  A  soft- 
ened spot  and  ill-defined  clot  in  the  cerebellum.  The  whole  cervical 
portion  of  the  spine,  but  particularly  anteriorly,  and  to  the  left  side, 


SPIXAL   HEMORRHAGE.  409 

was  imbedded  in  an  oblong  clot  of  dark  venous  blood  outside  the  mem- 
branes. The  whole  length  of  the  cervical  portion  of  the  canal  and  the 
dura  mater  were  deeply  tinged  by  the  color  of  the  clot.  The  cervical 
nerves  all  passed  through  this  effused  blood,  the  inter-vertebral  canals 
on  both  sides  being  filled  with  it.  So  soon  as  the  seventh  cervical  ver- 
tebra was  reached,  the  clot  ceased,  and  the  cord  and  canal  assumed 
their  normal  condition  and  color.  There  was  also  a  good  deal  of  semi- 
clotted  blood  about  the  pons  and  the  nerves  arising  from  it. 

"  It  is  certainly  a  matter  of  much  difficulty  to  account  satisfactorily 
for  this  great  effusion  of  venous  blood  in  a  subject  so  young  and  so 
apparently  healthy  and  robust.  No  outward  cause  could  be  assigned; 
there  had  been  no  blow  or  injury;  no  illness  ;  no  interrupted  function  ; 
but,  living  with  kind  and  affectionate  relations,  she  enjoyed  every  com- 
fort and  happiness.  It  might  have  been  assumed  that  so  great  a  lesion, 
situated  in  so  important  and  vital  a  position,  would  have  given  rise  to 
more  decided  and  grave  symptoms  from  the  beginning.  The  only 
probable  explanation  is,  that  the  effusion  took  place  very  gradually, 
had  room  to  extend  itself,  and  coagulated  slowly,  and  imperfectly. 
Until  the  paralysis  of  the  diaphragm  showing  dangerous  interference 
with  the  functions  of  the  phrenic  nerves,  nearly  every  symptom  might 
have  been  attributed  to  one  or  other  of  those  obscure  forms  of  hysteria 
so  frequently  met  with  in  practice." 

Prognosis. — Death  is  the  almost  invariable  result.  I  have,  however, 
known  two  instances  of  recovery.  In  one  of  these  the  patient,  a  boy 
of  about  fifteen,  was  thrown  from  his  horse.  Paralysis  supervened  im- 
mediately, and  there  was  a  severe  pain  at  about  the  eleventh  dorsal 
vertebra.  The  bladder  was  also  paralyzed.  For  several  weeks  his  life 
was  despaired  of,  but  he  eventually  recovered  with  the  paraplegia  re- 
maining, and  the  necessity  of  drawing  off  the  urine  with  a  catheter.  I 
saw  him  five  years  after  the  injury.  He  was  still  paraplegic,  and  the 
bladder  was  still  paralyzed.  Careful  examination  failed  to  show  any 
displacement  or  fracture  of  the  vertebra,  and  I  therefore  felt  warranted 
in  concluding  that  there  had  been  a  spinal  haemorrhage,  probably  men- 
ingeal. The  other  case  has  been  already  cited.  In  this,  the  patient 
fell  through  a  hatchway  a  distance  of  thirty  feet,  and  struck  on  his 
back.  Paralysis  was  almost  immediate.  He  came  under  my  care  fif- 
teen years  after  the  event,  and  I  diagnosticated  a  meningeal  spinal 
hemorrhage  from  the  fact  thai  there  had  been  violent  jerkings  of 
the  limbs  and  intense  Inmbar  pain.  There  were  do  signs  of  fractnre 
or  displacement.  Bui  in  these,  as  in  the  following  case,  which  T 
select  from  others  similar,  cited  by  .Mr.  Le  Groa  Clark,1  there  is,  of 
course,  room  for  doubl  relative  to  the  correctness  of  the  diagnosis. 

1  "  Lectures  on  the  Principles  <>f  Surgical  Diagnosis,  especially  in  Relation  to  Shock 
and  Visa  ral  Lesions,  delivered  before  the  Royal  College  of  Burg is  of  England,"  Lon- 
don, L870,  p.  1 16. 


410  DISEASES  OF  THE  SPINAL  CORD. 

The  patient,  a  man  thirty-six  years  of  age,  weighing  114-  stones, 
gave  the  following  account  of  himself  :  He  was  tripped  up  in  the  road, 
and  fell  heavily  on  his  left  hip,  and  then  turned  over  on  his  back.  On 
trying  to  rise,  he  failed,  not  having  any  power  of  movement  in  either 
lower  extremity.  He  was  at  once  brought  to  the  hospital.  On  admit- 
tance, he  complained  of  pain  in  the  lumbar  region,  and  there  was  slight 
tenderness  on  pressing  the  spinous  ridge  of  this  part  ;  but  careful 
examination  failed  to  detect  any  irregularity,  or  any  sign  of  mechanical 
injury  of  the  vertebral  column.  There  was  entire  loss  of  power  in  his 
lower  limbs — he  could  not  even  move  a  toe  ;  sensation  was  impaired; 
he  said  his  limbs  were  numbed.  There  was  slight  priapism,  and  he  was 
unable  to  micturate.  His  pulse  was  60  ;  but  there  were  no  signs  of 
well-marked  collapse.  On  the  third  day  he  was  able  to  move  his  toes 
a  little.  On  the  ninth  day,  sensation  was  perfect  ;  but  he  had  made 
very  little  progress  in  regaining  muscular  power.  Nearly  three  weeks 
elapsed  before  he  was  able  to  dispense  with  the  catheter  ;  and,  at  the 
expiration  of  five  weeks,  he  was  still  almost  as  helpless  in  moving  any 
part  of  his  lower  extremities.  He  remained  in  the  hospital  for  four 
months,  his  health  being  tolerably  good  throughout.  He  was  then  able 
to  get  about  very  fairly,  but  with  a  shuffling,  unsteady  gait." 

Mr.  Clark  then  remarks  : 

"  The  causative  accident  in  this  case  was  slight,  too  trivial  to  pro- 
duce fracture,  and  the  symptoms  were  not  those  of  sprain.  There  were 
no  physical  signs  of  displacement;  yet,  the  paraplegia  was  marked;  but 
not  including  corresponding  loss  of  sensation,  which  would  have  been 
present  if  a  displaced  vertebra  had  pressed  upon  the  cord.  The  slow 
recovery  was  a  gradual  confirmation  of  the  diagnosis,  that  fracture  with 
displacement  was  not  the  injury  to  which  the  symptoms  were  due. 

"  But,  I  must  admit,  I  cannot  dismiss  from  my  mind  that  in  these 
and  similar  protracted  cases,  there  is  something  more  than  simple  con- 
cussion needed  to  account  for  the  duration  of  the  symptoms;  probably 
extravasation  of  blood  into  the  theca  or  canal  which  is  slowly  absorbed. 
I  do  not  think  that  the  unequal  effects  produced  on  the  several  columns 
of  motion  and  sensation  forbid  this  supposition,  for  this  effect  is  by  no 
means  uncommon,  being  usually  in  favor  of  sensation,  where  the  in- 
equality is  noticed,  and  indicating  that  the  anterior  half  of  the  cord  and 
part  of  the  lateral  columns  are  the  parts  implicated.  A  child  three  and 
a  half  years  old  was  admitted  under  my  care,  who  had  been  run  over  by 
a  heavy  sand-cart,  sixteen  days  previously  ;  the  wheel  passed  over  the 
loins.  There  was  nothing  particular  noticed  at  the  time,  except  her  in- 
ability to  walk  as  well  as  usual.  This  inability  increased,  and,  when  seen 
by  me,  she  could  scarcely  manage,  when  held  up,  to  shuffle  her  feet  along. 
She  complained  of  no  pain,  had  no  difficulty  in  passing  her  water,  and 
the  sensibility  of  the  legs  seemed  to  be  in  no  degree  impaired.  On 
careful  examination,  there  was  nothing  abnormal  to  be  observed  in  any 


SPINAL  HEMORRHAGE.  41 1 

part  of  the  spine.  The  treatment  consisted  in  rest,  and  friction  of  the 
back  with  liniment  of  ammonia.  She  remained  in  the  hospital  five 
weeks,  and,  then  left  quite  well. 

"  A  remarkable  case  was  mentioned  to  me  by  the  late  Dr.  Dyer, 
who  acted  for  the  Brighton  Railway  Company.  A  man  was  injured  in 
a  collision  in  the  tunnel  four  or  five  miles  from  Brighton.  He  walked 
this  distance  with  some  difficulty  into  the  town,  and  within  twenty -four 
hours  became  entirely  paraplegic.  He  recovered  slowly,  and  after  the 
lapse  of  two  years  was  able  to  walk  as  well  as  before  the  accident. 
One  spot  on  the  back  was  always  tender,  and  continues  so  still  at  times. 
The  analogy  between  this  case  and  a  similar  but  fatal  injury  which  I 
have  already  mentioned,  seems  to  point  to  haemorrhage  as  the  probable 
cause  of  the  protracted  symptoms." 

Of  like  character  appears  to  have  been  the  following  case,  which  I 
cite  from  Dr.  John  Ashurst's '  admirable  monograph :  "  A  male  child 
of  two  years  was  admitted  to  the  Pennsylvania  Hospital  on  November 
13,  1861,  having  a  short  time  previously  received  a  severe  blow  upon 
the  back.  There  were  no  external  marks  of  injury,  but  the  lower  limbs 
were  paralyzed,  doubling  up  upon  themselves  when  an  effort  was  made 
to  place  the  child  in  an  erect  position.  He  was  discharged  cured,  after 
two  months,  his  treatment  having  consisted  in  little  else  than  rest  in  a 
recumbent  posture." 

Several  of  the  cases  given  by  Mr.  Erichsen,9  in  his  excellent  little 
work,  appear  to  present  many  of  the  features  of  spinal  haemorrhage. 
It  is,  therefore,  quite  probable,  making  all  due  allowance  for  uncer- 
tainty in  the  diagnosis,  that  the  affection  in  question,  especially  when 
resulting  from  traumatism,  is  not  an  entirely  hopeless  condition. 

Morbid  Anatomy  and  Pathology. — The  blood  in  haemorrhage  of 
the  spinal  cord  is  effused  either  into  the  substance  of  the  cord  or  into 
its  membranes.  It  may,  therefore,  be  situated  in  the  nervous  tissue  ; 
in  the  subarachnoidal  space;  in  the  intra-arachnoidal  space  ;  or  in  the 
space  between  the  dura  mater  and  the  walls  of  the  vertebral  canal. 
In  the  first-named  situation  the  gray  matter  is  invariably — so  far  as 
our  knowledge  extends — the  place  of  origination,  unless  we  except 
certain  possible  traumatic  cases.  The  clot  shows  a  greater  tendency  to 
extend  in  the  course  of  the  long  axis  of  the  cord  then  laterally,  and 
may  vary  in  length  from  half  an  inch,  or  less,  to  three  or  four  inches, 
Of  may  involve  the  whole  of  the  central  portion  of  the  cord.'  The 
■white  substance  rarely  gives  way  to  the  interior  pressure,  but  remains 
as  a  distinct  boundary  to  the  further  extension  of  the  clot  in  a  lateral 

•  "Injuries  of  the  Sj.inc,  with  an  Analysis  of  nearly  Four  Hundred  Cases,"  Phila- 
delphia, 1887,  p.  8. 

•"On  ion   of  (lie  Spine,  Nervous  Shock,  and  other  ObscilN   Injuries  of  tht 

Nervous  System  in  their  Clinical  and  Medico-Legal  aspects,"  London,  1875. 

J  Bayem,  op.  cC,  p.  L52;  Cruveilhier,  "Anatomic  pathologique,"  book  iii.,  plate  vt 


412  DISEASES  OF  THE  SPINAL  CORD. 

direction.  Occasionally,  however,  this  tissue  gives  way,  and  the  clot 
appears  as  a  tumor  under  the  meninges.  This  was  the  case  in  a  pa* 
tient  whose  clinical  history  is  related  by  Cruveilhier,  and  which  is  fur- 
ther remarkable  by  the  fact  that  five  years  before  the  attack  which 
terminated  in  death,  the  patient  had  experienced  suddenly  a  severe 
pain  in  the  neck,  and  paralysis  of  the  left  arm  and  leg.  He  recov- 
ered in  three  months.  The  post-mortem  examination  revealed  the  ex- 
istence of  an  old  apoplectic  cyst  in  addition  to  the  extravasation  of 
the  final  haemorrhage,  which  latter  extended  throughout  the  whole 
length  of  the  cord,  and  had  in  several  places  broken  through  the 
white  substance,  being  only  restrained  by  the  spinal  membranes. 

The  clot  may  either  present  the  general  appearance  of  blood,  and 
may,  in  fact,  consist  almost  entirely  of  this  substance,  or  it  may,  as  is 
the  case  in  cerebral  haemorrhage,  consist  of  blood  and  the  d&bris  of  the 
nervous  tissue.  The  changes  which  ensue  in  the  clot  and  in  the  limit- 
ing tissue  are  similar  to  those  which  take  place  in  the  brain  under  like 
circumstances. 

In  spinal  meningeal  haemorrhage  the  blood  is,  as  above  stated,  ex- 
tra vasated  between  the  bones  and  the  dura  mater — extra-meningeal 
haemorrhage  ;  between  the  layers  of  the  arachnoid — intra-arachnoidal 
haemorrhage  ;  or  between  the  arachnoid  and  the  pia  mater — subarach- 
noidal haemorrhage  : 

The  extra-meningeal  haemorrhages  are  those  which  are  especially 
apt  to  occur  as  the  result  of  traumatic  cause.  The  extravasation  is 
generally  extensive,  and  may  occupy  the  entire  extra-meningeal  space 
— though,  generally,  it  is  circumscribed  within  much  smaller  limits. 
The  cervical  region  is  most  apt  to  be  its  seat,  and  the  dorsal  next. 

In  intra-arachnoidal  spinal  haemorrhage  the  blood  is  not  effused  in 
such  large  quantity  as  in  the  variety  just  described,  and,  moreover, 
generally  has  its  source  in  a  cerebral  haemorrhage — rarely  being  autoc- 
thonous.  It  is  collected  in  a  sac,  and  may  exercise  more  or  less  com- 
pression on  the  cord  according  to  the  amount  extravasated. 

Sub-arachnoidal  haemorrhage  is  the  rarest  of  all  the  forms.  The 
blood  is  here  extravasated  into  the  meshes  of  the  pia  mater,  and  may 
compress  the  cord. 

Of  fifty-eight  cases  of  spinal-meningeal  haemorrhage,  cited  by 
Hayem,  thirty-eight  were  instances  in  which  the  blood  was  extravasated 
between  the  bones  and  the  dura  mater ;  eleven  were  intra-arachnoidal  ; 
and  eight  were  sub-arachnoidal. 

The  symptoms  which  follow  spinal  haemorrhage  are  the  results  of 
excitation  and  compression — the  hyperaesthesia  and  the  spasms  being 
due  to  the  former,  and  the  anaesthesia  and  motor  paralysis  to  the  latter. 

Treatment. — There  is  nothing  to  do  in  cases  of  spinal  haemorrhage 
but  to  maintain  the  patient  in  as  quiet  a  condition  as  possible,  and  to 
keep  ice  constantly  applied  to  the  vertebral  column.     If  there  is  time, 


SPINAL   MENINGITIS.  413 

ergot  might  be  administered  with  advantage.  In  two  cases  which  I 
have  had  the  opportunity  of  observing  from  the  first,  both  caused  by 
falls  from  the  loft  of  a  stable,  death  took  place  within  six  hours  ;  the 
symptoms  gradually  becoming  more  profound  and  advancing  upward. 
After  death,  the  haemorrhage  was  found  to  occupy  the  whole  length  of 
the  spinal  canal,  and  was  seated  between  the  bones  and  the  dura  mater. 
Of  course,  in  cases  like  these,  no  therapeutical  means  can  avail,  and, 
even  in  slighter  cases,  treatment  is  of  little  if  any  service.  We  may, 
however,  by  perfect  rest,  ice  to  the  spine,  leeches  to  the  anus,  and  the 
administration  of  ergot,  sometimes  prevent  haemorrhage  in  cases  of  in- 
juries of  the  cord  which  otherwise  might  be  followed  by  extravasation. 

In  cases  not  due  to  traumatism,  and  especially  in  those  which  are 
slow  in  their  progress,  more  is  to  be  expected  from  the  use  of  remedial 
measures.  Ergot  should  be  energetically  administered  in  large  doses, 
two  or  three  drachms  every  four  hours,  or,  what  is  perhaps  preferable, 
ergotin  should  be  given  to  the  extent  of  five  grains  hypodermically,  as 
often.  The  other  measures  above  mentioned  should  also  be  employed; 
with  the  view  of  causing  absorption  of  the  effused  blood,  the  actual 
cautery  applied  to  the  spine  in  the  vicinity  of  the  lesion  has  been 
recommended.  It  should  not  be  used  till  it  is  evident,  from  the  non- 
progressive character  of  the  symptoms,  that  the  extravasation  is  no 
longer  going  on. 

Strychnia  is  altogether  inadmissible  at  any  time  in  the  course  of 
the  disease. 


CHAPTER  IV. 

SPINAL   MENINGITIS. 


Inflammation  of  the  membranes  of  the  spinal  cord  may  be  eithor 
acute  or  chronic. 

ACUTE    SriNAL   MENINGITIS. 

Acute  inflammation  may  be  seated  either  in  the  dura  mater,  the 
arachnoid,  or  the  pia  mater  of  the  cord,  or  may  simultaneously  attack 
all  three  membranes. 

Symptoms. — The  symptoms  indicating  inflammation  of  the  dura  ma- 
tor  are  not  very  decided,  and  beyond  the  occurrence  of  pain  may  Dot 
be  observed  at  all.  When  combined  with  inflammation  of  the  arach- 
noid and  pia  mater,  the  phenomena  are  more  pronounced. 

Acute  inflammation  of  the  arachnoid  does  not  of  itself  give  rise  to 
characteristic  symptoms,  and  it  is  rarely  the  case  that  it  exists  sepa- 
rately. 


414  DISEASES  OF  THE  SPINAL  CORD. 

Acute  inflammation  of  the  pia  mater  can,  however,  be  recognized 
without  difficulty.  It  begins  with  a  chill,  as  do  others  of  the  phleg- 
masia?, and  this  is  soon  followed  by  febrile  excitement.  At  the  same 
time  there  is  intense  pain  in  the  back,  which  is  aggravated  by  every 
movement  of  the  patient,  but  not  by  pressure  on  the  part  of  the  spine 
over  the  diseased  portion  of  the  membrane.  Those  nerves  which  have 
their  origins  from  the  affected  region  are  the  seat  of  severe  pain,  which 
is  transmitted  through  their  trunks  and  branches  to  distant  parts  of 
the  body.  Spasms  of  the  muscles  of  the  back  are  commonly  present. 
These  are  tonic  in  character,  and  may  be  so  severe  as  to  bend  the 
body  backward,  producing  an  appearance  like  the  opisthotonos  of 
tetanus.  At  the  same  time  the  limbs  below  the  seat  of  the  lesion  are 
strongly  contracted.  I  have  witnessed  cases  in  which  the  knees  were 
drawn  up  to  the  chin,  and  the  heels  to  the  buttocks. 

At  the  same  time  there  is  impairment  of  motor  power  in  all  those 
parts  of  the  body  supplied  by  nerves  coming  from  the  cord  below  the 
diseased  region,  and  in  some  cases  voluntary  control  over  the  muscles 
is  entirely  lost. 

The  skin  is  generally  acutely  hypera?sthetic,  and  pressure  on  the 
muscles  below  the  lesion  usually  elicits  pain. 

While  the  affection  is  confined  to  the  membranes  of  the  lower  por- 
tion of  the  cord,  a  fatal  result  may  be  deferred  for  some  time,  and  the 
disease  may  become  chronic  ;  but,  if  it  extends  upward  so  as  to  in- 
volve the  region  from  which  the  phrenic  nerves  arise,  death  very  soon 
takes  place  by  asphyxia. 

So  long  as  the  spinal  cord  continues  free  from  the  disease,  the  reflex 
excitability  and  electro-muscular  contractility  remain  unimpaired. 

The  bladder  is  not  often  involved,  and  the  bowels  may  be  obstinately 
constipated,  or  the  fecal  matters  may  be  passed  involuntarily. 

CHKONIC   SPINAL   MENINGITIS. 

This  may  arise  in  consequence  of  an  acute  attack,  or  it  may  be  de- 
veloped spontaneously.  As  in  the  acute  form  of  the  affection,  pain 
constitutes  a  prominent  feature,  and  is  situated  both  in  the  spinal  region 
and  in  other  parts  of  the  body.  Spasms  and  contractions  of  the  lower 
extremities,  and  spasms  of  the  muscles  of  the  back,  are  likewise  promi- 
nent symptoms. 

The  pain  in  the  spine  is  not  increased  by  steady  pressure  over  the 
vertebrae,  but  it  is  greatly  aggravated  by  every  movement  of  the  body ; 
for  by  such  motion  the  nerves  are  compressed  as  they  leave  the  spinal 
canal,  and,  as  they  are  already  in  a  condition  of  erethism,  pressure  can 
not  be  borne. 

The  abnormalities  of  sensation  are  usually  in  the  way  of  hypersep* 
thesia,  which  may  sometimes  be  very  acute. 


SPINAL  MENINGITIS.  415 

The  paralysis  advances  gradually,  and  rarely,  at  first,  is  very  intense 
in  any  group  of  muscles.  It  is  likewise  subject  to  great  variations  in 
the  degree  of  severity.  Sometimes  the  patient  finds  that  he  walks 
tolerably  well  one  day,  while  the  next  he  can  scarcely  move  a  limb. 
These  differences  depend  on  the  amount  of  fluid  effused,  which  is  sub- 
ject to  changes  from  day  to  day. 

The  bladder  is  sometimes  paralyzed,  the  sphincter  may  be  similarly 
affected,  or  this  latter  may  be  subject  to  repeated  attacks  of  spasm, 
by  which  the  evacuation  of  the  urine  is  prevented. 

The  bowels,  as  in  the  acute  form  of  the  disease,  may  be  either  con- 
stipated, or  the  sphincter  ani  may  be  so  paralyzed  as  to  allow  of  the 
involuntary  passage  of  the  fecal  matters. 

Reflex  excitability  is  rarely  lessened,  and  is  often  considerably  in- 
creased. In  the  case  of  a  gentleman  from  Ohio  who  was  recently  un- 
der my  charge  for  chronic  spinal  meningitis,  the  slightest  touch  on  the 
sole  of  the  foot  was  sufficient  to  cause  the  limb  to  be  violently  drawn 
up;  and,  in  the  case  of  a  lady  from  New  Orleans  similarly  affected,  the 
contact  of  the  bedclothes  produced  a  like  effect. 

In  several  cases  I  have  observed  that  any  mental  agitation,  or  even 
the  attention  directed  to  the  affected  limbs,  was  sufficient  to  cause  vio- 
lent spasmodic  contractions. 

Electro-muscular  contractility  is  not  generally  impaired. 

The  symptoms  are  usually  aggravated  by  the  recumbent  posture. 

Bed-sores  are  a  frequent  accompaniment  of  chronic  spinal  menin- 
gitis. 

Causes. — The  most  common  cause  of  spinal  meningitis,  either  acute 
or  chronic,  is  exposure  to  cold  and  moisture.  Several  cases  have  come 
under  my  charge  which  clearly  resulted  from  lying  on  the  cold  and 
damp  earth,  and  from  going  to  sleep  in  this  situation.  In  one  case 
which  occurred  in  a  railway  conductor,  the  train  of  which  he  had  charge 
was  obstructed  in  its  passage  by  a  heavy  drift  of  snow.  While  work- 
men were  cutting  a  way  through  it,  he  lay  down  on  a  pile  of  snow,  and, 
being  greatly  exhausted,  quickly  fell  asleep.  Soon  after  being  awakened 
he  had  a  slight  chill  and  ;i  mild  fever,  and  the  following  day  experienced 
severe  pain  in  the  back.  This  was  soon  followed  by  the  other  symp- 
toms of  spinal  meningitis,  not  very  intense  in  character,  but  persistent, 
for  the  affection  passed  into  the  chronic  form.  Two  cases  have  come 
under  my  notice  in  which  the  disease  was  caused  by  the  back  being 
exposed  to  a  strong  and  cold  wind. 

On  account  of  this  influence  of  cold  in  producing  spinal  meningitis, 
the  disease  is  far  more   common  in  winter  than   in  summer.     Of  the 
cases  that    1   have   treated   wholly  or  in   part  during  the  last    t\\ 
years,  by  far  the  greater  number  occurred  in  tho  months  from  Novem- 
ber to  March,  inclusive. 

Exposure  to  the  direct  rays  of   the    sun  is  said  to   induce  spinal 


416  DISEASES  OF  THE  SPINAL  COED. 

meningitis,  but  I  have  never  witnessed  a  case  in  which  this  cause  could 
reasonably  be  inferred.  I  may  make  the  same  remark  in  regard  to 
the  effects  of  strong  muscular  exercise. 

It  is,  however,  sometimes  a  consequence  of  wounds  and  injuries. 
Seven  of  the  cases  under  my  charge  were  due  to  traumatic  causes. 

Rheumatism  is  likewise  an  occasional,  and  syphilis  quite  a  com- 
mon cause. 

Diagnosis. — The  diagnostic  phenomena  of  spinal  meningitis,  either 
of  the  acute  or  chronic  form,  arc  the  pain  in  the  back,  increased  on  any 
movement  of  the  spinal  column  ;  the  pains  in  the  course  of  the  nerves 
having  their  origin  from  the  diseased  region  ;  the  tonic  spasms  of  the 
muscles  of  the  back,  and  of  other  parts  of  the  body  ;  the  exaltation  of 
reflex  excitability  and  hyperesthesia  ;  and  the  variations  which  take 
place  in  the  extent  and  intensity  of  the  paralysis. 

Prognosis. — The  course  of  spinal  meningitis  is  generally  progressively 
onward  to  a  fatal  termination — the  patient  dying  either  by  the  gradual 
extension  of  the  disease  upward  so  as  to  involve  more  important  nerves 
in  the  lesion,  by  the  development  of  some  intercurrent  affection,  or  by 
exhaustion.  I  have,  however,  seen  five  cases  in  which  the  disease  was 
arrested,  three  of  which  will  be  more  specifically  referred  to  under  the 
head  of  treatment.  And  Ollivier,1  Brown-Sequard,9  and  Jaccoud,3  admit 
the  possibility  of  cure.  When  of  syphilitic  origin  the  prognosis  is 
much  more  favorable. 

Morbid  Anatomy  and  Pathology. — The  lesions  found  after  death 

from  spinal  meningitis  may  be  confined  to  any  one  of  the  membranes, 
but  more  generally  are  restricted  to  the  pia  mater  and  the  sub-arach- 
noid space.  They  consist  in  thickening  of  the  membrane,  spots  of 
opacity,  turgidity  of  the  vessels,  and  the  effusion  of  a  large  quantity  of 
spinal  fluid.  This  fluid  is  occasionally  clear,  but  is  more  frequently  full 
of  flocculent  matter,  or  is  tinged  with  blood. 

The  alterations  found  in  the  arachnoid  are  of  similar  character,  with 
the  addition  that  there  are  numerous  hard  cartilaginous  plates  scattered 
through  the  diseased  part  of  the  membrane,  which  vary  in  size  from 
that  of  a  grain  of  wheat  to  a  mustard-seed. 

The  dura  mater,  when  it  has  been  the  seat  of  inflammation,  becomes 
thickened  and  adherent  to  the  bone.  Occasionally  it  is  perforated  by 
the  supervention  of  gangrene,  and  the  pus  collected  between  it  and 
the  vertebrae  escapes  into  the  space  between  the  dura  mater  and  arach- 
noid, and  excites  general  meningitis. 

Ollivier  reports 4  the  case  of  a  child  three  or  four  years  old,  whc 
entered  the  hospital  February  2,  1823.     There  were  great  difficulty  of 

1  "  Traitd  dcs  maladies  de  la  moelle  6piniere,"  etc.,  Paris,  1827,  tome  ii.,  p.  295. 
a  Op.  cil.,  p.  302.  •  Op.  cit.,  p.  82. 

*  "Traite  des  maladies  de  la  moelle  cpiniere,"  troisieme  Edition,  Paris,  1837,  tome  ii., 
p.  272. 


SPINAL   MENINGITIS.  417 

deglutition,  a  remarkable  fixedness  of  the  eyes,  tetanic  convulsions — 
trismus,  opisthotonos — coma,  and  permanent  contractions  of  the  lower 
extremities.  Death  ensued  on  the  twelfth  day  after  admission.  On 
post-mortem  examination  the  membranes  of  the  brain  were  found  to  be 
thickened  and  opaque,  the  substance  of  the  organ  was  injected,  and  the 
ventricles  contained  an  excessive  amount  of  fluid.  In  the  spine  at  the 
middle  of  the  dorsal  region,  there  was  a  very  thick  reddish  infiltration 
in  the  cellular  tissue,  between  the  dura  mater  and  the  bony  canal.  On 
incising  the  membranes,  it  was  seen  that  their  cavity  was  filled  with 
serum;  the  vessels  of  the  pia  mater  were  intensely  congested.  The  sub- 
stance of  the  cord  was  slightly  injected. 

Michaud,1  under  the  name  of  external  pachymeningitis,  has  de- 
scribed an  inflammation  of  the  dura  mater,  which  he  has  found  to  be 
the  affection  of  the  membranes  generally  produced  by  Pott's  disease. 
It  consists  in  a  thickening  of  the  dura  mater  by  deposits  of  yellow- 
colored  granulations,  which  by  their  confluence  form  plates  which  are 
attached  by  their  inferior  surface  to  the  membrane.  Under  them  the 
dura  mater  appears  to  be  healthy.  At  first  they  are  only  developed  in 
the  vicinity  of  the  osseous  lesion,  but  they  have  a  tendency  to  extend, 
and  may  involve  the  whole  length  of  the  membrane.  The  existence  of 
these  formations  was  first  noticed  by  E.  Wagner J  in  a  case  of  Pott's 
disease,  of  which  he  made  the  post-mortem  examination.  This  inflam- 
mation of  the  dura  mater  may  result  in  little  abscesses,  scattered 
through  its  lamina,  or  larger  collections  of  pus  may  be  formed  in  the 
substance  of  the  new  formation. 

The  symptoms,  as  Leyden 3  and  Rosenthal 4  admit,  are  simply  those 
of  the  other  forms  of  spinal  meningitis. 

The  internal  surface  of  the  dura  mater  may  also  be  the  seat  of 
morbid  processes.  Two  of  these  modes  have  been  differentiated.  One 
constitutes  the  cervical  hypertrophic  pachymeningitis  of  Charcot ;  * 
the  other  is  the  internal  hemorrhagic  pachymeningitis  of  A.  Meyer ' 
and  others.  As  described  by  Charcot,  cervical  hypertrophic  pachy- 
meningitis consists  in  an  alteration  of  the  meninges,  especially  the  dura 
mater.  The  seat  of  the  lesion  is  variable,  but  the  cervical  enlargement 
appears  to  be  the  place  generally  affected.  The  alteration  of  the  dura 
mater  is  the  primary  fact;  the  other  membranes,  the  cord  itself,  and  the 
nerves  coming  from  it,  subsequently  become  involved.  Formerly,  the 
disease  waa  mistaken,  as  by  Laennec,  Andral,  and  J  hit  in,  for  a  primary 

1  "  Sur  l;i  meninglte  et  la  invi-lite  dans  le  mal  vertebral,"  Paris,  1871,  p.  9. 
* u  Pathologischee,  anatomischea  mid  klinischea  Beitr&ge  vox  Kentniss  der  Gefasa- 
nervon,"   Archiv  tkr  Heilkuads,  Ileft  4,  1870,  S.  321. 

'  "  Klinik  der  RQckenmarka-krankheitan,"  Berlin,  1*71,  Enter  Band,  B.  B88, 

4  "Klinik  der  Neiren-krankheiten,"  Stuttgart,  is75,  S.  280. 

5  "  MtMimiivs  i|i-  Ia  Soeieto  '!.■  Iliolngie,"  1871,  p.  35,  and  "  Lccxms  sur  les  maladies 
du  Bjtteme  neireux,"  Paris,  1871,  p.  246. 

•  "  Dc  Pachymeningitide  oerebro-apinali  Interna,"  Bonnac.  18C1. 
28 


418 


DISEASES  OF  THE  SPINAL  CORD. 


affection  of  tbe  spinal  cord,  and  was  described  by  them  as  hypertro- 
phy of  this  organ  ;  and  the  error  is  in  a  measure  sustained  by  the  fact 
that,  in  cases  of  the  disease  in  which  the  vertebral  canal  is  opened, 
the  spinal  cord  and  its  membranes  are  seen  to  completely  fill  the  canal. 

But,  upon  making  a  transverse  section  of  the  cord,  it  is  at  once 
perceived  that  the  swelling  is  due  to  the  thickening  of  the  envelopes, 
and  that  the  marrow,  so  far  from  being  enlarged,  is  in  reality  com- 
pressed and  flattened  from  before  backward. 

In  the  accompanying  engraving  (Fig.  31),  taken  from  JoffroyV 


Fig.  31. 


memoir,  the  appearances  are  well  exhibited  (a,  the  hypertrophied  dura 
mater;  b,  nerve-roots  traversing  the  thickened  membranes;  c,  the  pia 
mater  confounded  with  the  dura  mater  ;  d,  lesions  of  chronic  myelitis  ; 
e,  section  of  canals  newly  formed  in  the  gray  substance). 

As  will  readily  be  perceived,  the  pia  mater  is  involved  in  the  morbid 
process,  but  not  to  the  same  extent  as  the  dura  mater.  This  latter, 
when  carefully  examined,  is  seen  to  be  composed  of  numerous  con- 
centric layers,  and  is  adherent  on  the  outside  to  the  vertebral  ligament, 
and  on  the  inside  to  the  pia  mater. 

Sometimes  the  thickened,  hypertrophied  membrane  seems  to  be  con- 
stituted of  two  layers  ;  the  one  external,  the  other  internal.  This  last, 
which  appears  to  be  a  new  formation,  consists  of  a  dense  fibroid  tissue. 
It  is,  therefore,  quite  distinct  from  those  soft  and  very  vascular  neo- 
membranes  which,  in  the  spinal  as  well  as  in  the  cerebral  dura  mater 
give  rise  to  hasmatoma — constituting  in  the  former  the  internal  htemor- 
rhagic  pachymeningitis  to  be  presently  described. 

The  spinal  cord  itself  participates  in  the  alteration,  which  has  all 
the  characteristics  of  a  transverse,  irregularly  disseminated  myelitis,  at 
tacking  as  well  the  central  gray  matter  as  the  white  columns. 

The  peripheric  nerves  are  affected  by  the  spinal  lesion,  both  in  their 
radicles  within  the  cord,  and  in  their  trunks,  as  they  pass  through  the 
thickened  and  inflamed  membranes.     The  anterior  and  posterior  roots 
1  "  De  la  pachym6ningite  cervicale  hypertrophiquc,"  Th6se  de  Paris,  1873 


SPINAL   MENINGITIS. 


419 


are  about  equally  involved,  and  hence,  as  symptoms,  there  are  both 
derangements  of  motion  and  of  sensibility. 

The  symptoms,  as  given  by  Charcot,  are,  in  the  first  place,  extremely 
violent  pains,  which  occupy  mainly  the  posterior  part  of  the  neck,  but 
which  extend  to  the  top  of  the  head  and  to  the  superior  extremities.- 
These  pains  are  accompanied  with  rigidity,  especially  marked  in  the 
neck,  which  is  immobile,  as  in  Pott's  disease,  occupying  the  sub-occip- 
ital region.  They  are  generally  quite  constant,  but  are  more  violent 
at  some  times  than  at  others.  They  extend  to  the  joints,  which,  how- 
ever, are  not  ordinarily  the  seat  of  swelling,  and  with  these  pains  there 
are  the  various  sensations  of  numbness  in  the  superior  extremities,  and 
some  degree  of  paralysis.  Sometimes  there  are  bulbous  and  pemphi- 
goid eruptions. 

The  second  period  is  characterized  by  other  symptoms,  which  appear 
to  be  due  to  the  extension  of  the  meningeal  lesion  to  the  spinal  cord, 
and  to  a  more  profound  alteration  of  the  peripheric  nerves. 

The  limbs  cease  to  be  painful,  but  they  become  paralyzed,  and  the 
muscles  are  atrophied,  and  the  atrophy  extends  to  all  the  muscles  of 
the  extremity.  But,  speaking  only  of  the  muscles  of  the  arm  and  fore- 
arm, it  is  notable  that  those  which  receive  their  innervation  from  the 
ulnar l  and  median  nerve  are  especially  affected,  while  those  which  are 
supplied  by  the  radial  nerve  almost  entirely  escape.     From  this  pecul- 


Fig.  32. 


iarity  ;i  certain  character  of  deformity  results,  which,  though  met  with 
in  other  diseases,  and  ool  always  seen  in  the  affection  nnder  notice,  is, 
nevertheless,  ool  a  feature  <>!'  other  forms  of  muscular  atrophy.  It  is, 
consequently,  a  diagnostic  mark  of  some  value  (Fig.  82).     To  these 

1  M.  Charcol  Bays,  du  rurf  radial  et  <lu  „,,-/  mSdion,  but  it  ia  evident  from  the  con- 
text, as  well  .i-  fr what  follows,  thai  radial  ii  ■  mispriiKl  for  cubital  {op.  <■>  .,  p.  261) 

Tin-  cut  al-i'  Bhowi  the  error. 


420  DISEASES   OF   THE   SPINAL   CORD. 

symptoms  are  added  contractions,  and  often  anaesthesia,  which  may  ex- 
tend from  the  extremities  to  the  trunk.  After  a  while,  the  inferior 
extremities  become  paralyzed,  and  eventually  contractions  ensue  in 
them  also. 

Charcot  does  not  regard  hypertrophic  pachymeningitis  as  a  neces- 
sarily incurable  affection:  for  a  woman,  who,  for  five  or  six  years,  ex- 
hibited all  its  characteristic  symptoms,  being  confined  to  her  bed  for  a 
long  period,  recovered  so  far  as  to  be  able  to  walk  and  to  use  her  hands 
in  some  labors. 

Interned  hemorrhagic  pachymeningitis  is,  in  the  spinal  canal,  the 
analogue  of  cerebral  pachymeningitis  or  hasmatoma  of  the  dura  mater. 
Its  differentiation  from  spinal  meningitis  was  first  made  by  Albers, 
though  he  failed  to  indicate  its  characteristic  features.  A.  Meyer 1  first 
pointed  out  its  essential  nature.  An  officer  had  for  some  time  been 
subject  to  vertigo,  accessions  of  heat,  and  arterial  throbbings,  in  the 
head  and  back.  He  recovered,  but  was  subsequently  seized  with  paral- 
ysis, mental  derangement,  incontinence  of  urine,  and  agonizing  pains  in 
the  head.  When  these  symptoms  had  lasted,  with  gradually-increasing 
intensity,  for  about  a  year,  he  died.  The  autopsy  revealed  the  exist- 
ence of  cerebral  meningitis,  and  of  a  false  membrane  attached  to  the 
cranial  dura  mater,  and  to  the  same  membrane  in  the  vertebral  canal  as 
far  down  as  the  last  dorsal  vertebra.  This  membrane  was  fibrous,  and 
composed  of  several  laminae,  between  which  were  extravasations  and 
masses  of  pigment.  Other  cases  have  been  recorded  by  Magnan  and 
Bouchereau,3  as  the  result  apparently  of  chronic  alcoholism  ;  and  by 
Charpy  s  and  Simon,4  as  accompanying  insanity  and  general  paralysis. 

Internal  haemorrhagic  pachymeningitis  is  rarely  unaccompanied  by 
lesions  of  the  brain,  and  is  generally  associated  with  the  like  intra- 
cranial disease. 

The  morbid  anatomy  appears  to  differ  in  no  essential  respect  from 
the  analogous  affection  of  the  cranial  dura  mater,  and  the  symptom- 
atology is  not  sufficiently  characteristic  to  admit  of  its  recognition 
during  life. 

In  cases  of  chronic  spinal  meningitis,  due  to  syphilitic  taint,  the 
symptoms,  as  in  the  analogous  condition  of  the  cerebral  membranes,  are 
jj-enerally  much  more  restricted,  and  may  involve,  as  they  usually  do, 
the  meninges  in  relation  with  the  antero-lateral  columns  only.  In  such 
rases  the  lesion  is  presumably  circumscribed,  and  the  gummy  exudation 
is  likewise  limited.  The  symptoms  then  relate  almost  entirely  to  the 
power  of  motion,  either  of  one  or  both  lower  extremities,  and  there  is 

1  Op.  cit. 

■  "  Memoircs  de  la  Societe  de  Biologie,"  1869. 

3  Cited  from  unpublished  notes,  by  Hayera,  op.  cit.,  p.  90. 

4  "  Ueber  den  Zustand  des  Riiekenmarks  in  dcr  Dementia  paralytica,"  Grksinyer's 
Archiv,  Heft  "7  u.  2. 


SPINAL  MENINGITIS.  421 

thus  mor6  or  less  extensive  paraplegia.  The  lower  dorsal  and  upper 
lumbar  regions  are,  in  my  experience,  almost  the  only  parts  of  the  cord 
attacked  in  such  cases  ;  though  I  have  occasionally  "witnessed  instances 
in  which  the  lesions  were  multiple,  some  of  them  being  high  up  in  the 
cord. 

In  an  interesting  case,  the  details  of  which  are  very  fully  given  by 
Jaccoud,1  a  man  was  paralyzed  in  both  lower  extremities.  When  the 
patient  came  under  observation,  the  paraplegia  had  already  lasted  two 
months,  and  had  been  fully  developed  in  three  days  :  standing  was  im- 
possible, the  right  leg  was  more  paralyzed  than  the  left  ;  there  were 
neither  contractions  nor  atrophy  ;  there  were  no  involuntary  move- 
ments ;  the  motility  of  the  trunk  and  superior  extremities  was  perfect ; 
electro-muscular  excitability  was  not  impaired  ;  tactile  sensibility  and 
sensibility  to  pain  and  heat  were  normal  in  the  right  inferior  extremity; 
but  in  the  left,  though  tactile  sensibility  was  good,  the  sensibility  to 
pain  and  heat  was  impaired  ;  indeed,  the  sensation  to  impressions,  ordi- 
narily painful,  was  entirely  lost  throughout  the  whole  extent  of  the  limb. 

In  regard  further  to  the  case  of  which  I  have  ij-iven  but  a  brief 
abstract,  M.  Jaccoud  remarks: 

"The  nature  of  the  lesion  can  be  very  easily  determined.  The  para- 
plegia was  developed  in  three  days,  in  an  apparently  healthy  man.  There 
had  been  no  fever,  pains,  sensation  of  constriction,  convulsions,  or  con- 
tractions. The  lesion  was  very  limited,  the  portion  of  the  cord  situated 
ibove  was  not  altered,  and  the  morbid  process  involved  one  side  more 
than  the  other.  I  know  of  no  condition  which  fulfills  all  these  phe- 
nomena but  compression  of  the  cord.  Paraplegia  of  rapid  invasion  is 
observed,  it  is  true,  in  acute  myelitis,  in  acute  meningitis,  in  spinal 
haemorrhage,  in  meningeal  spinal  congestion,  and  in  hydrorachis;  but  it 
is  then  accompanied  with  fever  or  pain,  symptoms  which  have  been 
entirely  absent  in  our  patient.  Moreover,  these  lesions  do  not  produce 
so  limited  a  disorder  as  that  before  us.  The  compression  of  the  cord 
in  this  case  is  from  before  backward,  and  the  anterior  columns  are  more 
affected  than  the  posterior;  but  on  the  right  side  the  compression  has 
involved  the  gray  sensory  elements  of  the  posterior  spinal  system, 
leading  to  loss  of  thermic  and  painful  sensibility  in  the  left  lower  es 
tremity. 

"Such  is  the  pathogenetic  diagnosis  of  our  paraplegic  patient  ;  it  ia 
founded  entirely  on  the  physiological  interpretation  of  the  symptoms; 
and,  as  the  case  is  very  strongly  marked,  analysis  permits  us  to  notice 
nil  the  particularities  of  the  lesion  of  the  cord.  You  can  ask  nothing 
more  complete;  it  is  a  physiological  diagnosis  par  excellence  ;  it  is  per- 
fect. Here,  gentlemen,  appears  the  superiority  of  medical  over  physio* 
logical  diagnosis  ;  and  I  am   happy  that  this  occasion  permits  mo  to 

■  M LeQons  de  cliflique  medicate  faitee  a  L'Hftpital  de  la  Charitc',"  denxi&me  ftdition, 

Paris,  1869,  p.  446. 


422  DISEASES   OF   THE   SPINAL   CORD. 

insist  upon  your  appreciation  of  this  capital  truth,  that  others  havo 
vainly  opposed.  What  does  this  very  exact  physiological  diagnosis 
teach  us  in  regard  to  the  prognosis  ?  Nothing,  absolutely  nothing  ;  it 
is  a  dead  letter.  Our  patient  has  a  compression  of  the  cord  at  the 
tenth  dorsal  vertebra.  This  compression  is  stronger  on  the  right  than 
on  the  left  side;  it  has  interrupted  the  conductibility  of  the  motor  col- 
umns of  the  cord  on  both  sides,  and  of  the  sensory  columns  on  the 
right  side,  but  it  has  not  interfered  with  the  posterior  white  columns, 
or  the  two  orders  of  nerve-roots.  But,  knowing  all  this,  are  we  the 
better  enabled  to  be  of  use  to  our  patient,  who  cares  only  for  one 
thing,  and  that  is  the  recovery  of  the  use  of  his  legs  ?  No  1  a  thousand 
times  no  1  These  scientific  data,  acquired  with  such  labor,  are  sterile, 
and  our  physiological  diagnosis  is  powerless  to  help  us.  It  teaches  us 
nothing  relative  to  the  probable  issue  of  the  disease;  nothing  touching 
the  treatment  to  be  employed.  But  let  us  substitute  the  physician  for 
the  physiologist;  let  us  bring  the  principles  of  clinical  diagnosis  to  bear 
upon  the  subject,  and  we  shall  discover  something  of  the  future  of  the 
patient,  and  how  we  are  to  treat  him.  This  man  is  syphilitic,  and  that 
one  word,  which  is  the  index  of  the  medical  diagnosis,  at  the  same  time 
points  out  to  us  the  nature  of  the  compression  which  the  cord  is  under- 
going, reveals  the  prognosis  of  the  paraplegia,  and  directs  us  as  to  the 
treatment  to  be  employed. 

"  This  patient  has,  up  to  this  time,  had  none  of  the  accidents  called 
secondary;  he  certainly  has  not  yet  reached  the  tertiary  stage;  at  most 
we  can  only  say  that  he  has  arrived  at  that  transition  stage  which  often 
separates  superficial  from  profound  syphilitic  determinations.  He  pre- 
sents no  visible  lesion  of  the  bones,  and  in  that  situation  we  could  only 
allege  an  exostosis  or  a  vertebral  periostitis  as  a  cause  of  the  compres- 
sion of  the  cord.  I  am  more  inclined  to  believe  that  the  lesion  is  one 
of  those  meningeal  affections  of  the  kind  described  by  Knorre,1  con- 
sisting in  circumscribed  exudations,  which  may  remain  latent  if  they 
are  very  small,  but  which,  if  large,  may  cause  compression  and  conse- 
quent paraplegia." 

The  patient  ultimately  recovered,  under  the  use  of  the  bichloride  of 
mercury  and  the  iodide  of  potassium. 

A  case,  very  nearly  identical  in  its  chief  features  with  that  of  M. 
Jaccoud,  came  under  my  care  a  few  months  since,  in  consultation  with 
Dr.  Van  Wyck,  of  this  city,  in  which  recovery  was  complete  under  like 
treatment. 

In  relation  to  these  exudations  of  the  spinal  membranes,  Vir- 
chow a  declares  that  little  is  known  of  their  morbid  anatomy  ;  and 
Charcot 8  asserts  that  they  are  not  common — basing  his  opinion,  how- 

1  "  TJeber  syphilitische  Lahmungen,"  Deutsche  Klinik,  1849. 

8  "  Pathologie  des  tumeurs,"  Paris,  1869,  tome  ii.,  p.  454. 

8  "  Lecons  sur  lea  maladies  du  systome  nerveux,"  deuxiome  partie,  second  fasci- 
cule, p.  80. 


SPINAL  MENINGITIS.  423 

ever,  only  on  the  small  number  of  post-mortem  examinations  which 
have  been  made,  in  which  these  formations  have  been  found  A  parity 
of  reasoning  would  throw  hysteria,  for  instance,  out  of  nosology  alto- 
gether. "We  are  not  likely  to  have  much  information  in  regard  to  the 
morbid  anatomy  of  so  curable  a  disease  as  syphilitic  spinal  meningitis. 
So  far  as  our  information  extends,  the  condition  induced  in  the  spinal 
membranes  by  syphilids  does  not  differ  essentially  from  that  caused  by 
the  same  influence  in  the  cerebral  membranes,  and  which  has  been  fully 
considered  in  the  present  work  under  the  head  of  basilar  cerebral 
meningitis.  In  this  view  I  am  supported  by  Buzzard,1  Lagneau,5  Gros 
and  Lancereaux,9  Zambaco,4  and  others. 

The  theory  of  the  symptoms  observed  in  spinal  meningitis  is,  that 
they  are  due  to  two  immediate  causes,  excitation  and  pressure.  The 
former  is  the  result  of  the  hyperaemia,  the  latter  of  the  exudation, 
or  of  the  increased  amount  of  spinal  fluid  causing  pressure. 

Treatment. — In  the  acute  form  of  spinal  meningitis,  active  meas- 
ures are  required.  The  application  of  leeches  to  the  painful  part  of  the 
spine,  or  of  cups,  so  as  to  effect  local  depletion,  will  generally  prove 
useful.  Hydragogue  cathartics  are  also  beneficial,  for  by  their  action 
the  vessels  of  the  inflamed  membranes  are  depleted  of  their  blood,  and 
the  excessive  amount  of  spinal  fluid  effused  is  in  consequence  more 
readily  absorbed. 

Mercury  may  also  be  advantageously  administered  either  by  inunc- 
tions with  mercurial  ointment  or  by  calomel  given  internally,  or  by  both 
these  means.  Calomel  should  be  given  in  doses  of  from  one  to  two 
grains  every  three  or  four  hours,  till  the  system  is  brought  under  its 
influence,  as  manifested  by  fetor  of  the  breath. 

The  patient  should  be  kept  as  quiet  as  possible,  and  should  be  en- 
joined not  to  He  on  the  back.  For  the  relief  of  the  dorsal  and  other 
pains,  suppositories,  containing  each,  half  a  grain  of  codeine,  are  often 
efficacious.     They  may  be  administered  night  and  morning. 

In  the  chronic  form  of  the  disease,  depletion  by  bloodletting  in  any 
form  is  not  so  beneficial  as  in  the  acute  variety  or  as  in  spinal  conges- 
tion. Blisters  are  more  admissible,  and  scarcely  ever  fail  to  do  good. 
They  should  be  applied  on  each  side  of  the  spinal  column  near  the 
diseased  region  of  the  cord,  and  as  soon  as  one  heals  another  should 
take  its  place.  Purgatives  are  also  useful  for  the  same  reasons  which 
prevail  in  acute  spinal  meningitis. 

Iodide  of  potassium  is  always  a  valuable  agent,  inched  more  so  than 
any  other  remedy  employed  in  chronic  spinal  meningitis.     I  employ  it 

1  "  Clinical  Aspects  of  Syphilitic  Nervous  Affections,"  London,  1874,  p.  TO. 
1  "  Maladies  syphilitiqucs  du  systfcme  ncrveux,"  Taris,  1860. 
*  "  Dcs  affections  nervcuscs  sypliilitiques,"  Taris,  1SG1. 
■  Ibid.,  Taris,  1802. 


424  DISEASES  OF  THE  SPINAL  COED 

La  the  foim  of  a  saturated  solution,  which  contains  about  a  grain  to 
each  drop.  Of  this,  I  administer  the  first  day  seven  drops  three  times, 
preferably  before  meals;  the  next  day  eight  drops  to  the  dose,  the  next 
nine,  and  so  on,  till  the  patient  takes  from  forty  to  sixty  drops  at  the 
dose,  according  to  circumstances.  The  iodide  of  potassium  always  acts 
best  when  largely  diluted  with  water,  so  that,  as  the  doses  are  increased, 
an  additional  quantity  of  water  should  be  used. 

I  very  often  employ  the  corrosive  chloride  of  mercury  in  combina- 
tion with  the  iodide  of  potassium,  in  doses  of  the  sixteenth  of  a  grain 
with  each  dose  of  the  iodide. 

The  treatment  with  iodide  of  potassium  and  mercury  is  still  more 
strongly  indicated  in  those  cases  which  are  of  syphilitic  origin. 

Diuretics  may  also  frequently  be  given  with  advantage.  Their 
object  is  the  same  as  that  which  governs  in  the  administration  of 
purgatives. 

In  two  of  the  cases  cured,  to  which  reference  has  been  made,  I 
derived  the  greatest  benefit  from  repeated  blisters,  and  the  persistent 
use  of  iodide  of  potassium.  The  latter  was  carried  to  the  extent  of 
fifty  grains  three  times  a  day  in  one  of  these  cases,  and  sixty-five  in 
the  other. 

At  the  same  time  the  primary  galvanic  current  was  applied  to  the 
spine  in  the  manner  recommended  for  spinal  congestion,  and  the  in- 
duced current  to  the  paralyzed  limbs.  I  am  very  sure  that  electricity 
in  both  these  forms  should  be  used  in  most  cases  of  chronic  spinal 
meningitis.  The  following  case,  reported  by  J.  Frank,1  and  quoted  by 
Ollivier,3  of  acute  spinal  meningitis,  is  instructive: 

"A  captain,  aged  forty-two  years,  of  sanguineo-bilious  tempera- 
ment, subject  to  rheumatic  pains  and  haemorrhoids,  and  addicted  to  the 
use  of  alcoholic  liquors,  was  suddenly  seized  on  the  evening  of  the  2d 
of  March,  1819,  with  a  chill,  which  was  soon  succeeded  by  a  burning 
fever,  accompanied  by  pain  in  the  lumbar  region.  During  the  night 
the  pain  increased,  extended  as  high  up  as  the  occipital  region,  and 
gradually  acquired  great  intensity.  J.  Frank  was  called  in  the  morning 
at  five  o'clock,  to  see  the  patient,  who  was  suffering  acutely.  He  was 
uttering  loud  groans,  was  lying  on  his  belly,  with  the  superior  and  in- 
ferior extremities  stretched  out  to  their  full  length.  To  the  questions 
put  to  him,  the  patient  answered  with  great  difficulty  that  he  had  pains 
all  over  his  body,  that  he  was  unable  to  open  his  eyes,  that  his  teeth 
were  strongly  clinched,  and  that  a  burning  and  pulsating  pain  extended 
from  the  occiput  to  the  lower  extremity  of  the  vertebral  column.  The 
limbs,  especially  the  inferior,  were  without  sensation,  but  were  agitated 
by  occasional  jerkings.  There  was  such  a  constriction  of  the  chest  that 
breathing  was  scarcely  possible,  and  the  abdomen  was  likewise  in  a 

1  "  Praxeos  Med.,  etc.,  de  rachialgite,"  tome  vi.,  p.  76,  Turin,  1 S22. 
'  Op.  tit,  d.  295. 


SPINAL  MENINGITIS.  495 

state  of  contraction.  There  were  constipation,  incontinence  of  urine,  a 
pulse  soft  but  100  per  minute,  occasional  palpitations  of  the  heart,  and 
a  hot  and  dry  skin. 

"  Frank  at  once  opened  a  vein  in  the  foot,  and  abstracted  sixteen 
ounces  of  blood.  A  dozen  leeches  were  applied  around  the  occiput, 
and  as  many  scarified  cups  on  each  side  of  the  spine.  A  decoction  of 
tamarinds  was  given  as  a  cathartic.  These  means  were  sufficient  to 
restore  the  health  of  the  patient  in  a  few  days.  The  bloodletting  pro- 
duced an  almost  immediate  cessation  of  all  the  symptoms  ;  for,  a  short 
time  after  its  employment,  the  movement  of  the  eyelids  became  easy, 
as  well  as  that  of  the  jaw;  sensation  reappeared  in  the  extremities,  and 
the  dorsal  pain  diminished  considerably  in  intensity." 

As  Ollivier  remarks  in  regard  to  this  case,  several  of  the  symptoms 
are  those  of  spinal  congestion.  The  sudden  supervention  of  the  disease, 
as  well  as  its  rapid  disappearance,  points  to  that  affection.  Nevertheless, 
its  general  features  are  those  of  acute  spinal  meningitis — an  affection 
which,  of  course,  cannot  exist  without  congestion. 

In  a  very  interesting  case  under  my  charge  several  months  ago,  a 
cure  of  the  spinal  disorder,  which  was  chronic  spinal  meningitis  prob- 
ably of  syphilitic  origin,  was  accomplished  by  the  use  of  the  iodide  of 
potassium  and  the  corrosive  chloride  of  mercury,  as  recommended  on 
pages  149  and  450.  In  this  case  the  affection  had  lasted  for  several 
years,  and  extended  from  the  occiput  to  the  lower  extremity  of  the 
spinal  coid.  The  limbs  were  constantly  subject  to  violent  spasmodic 
jerkings,  and  both  legs  and  one  arm  were  in  a  permanent  state  of  con- 
traction, which  had  existed  for  three  years.  Under  the  use  of  the  iodide 
and  the  mercury,  as  mentioned,  the  pain,  which  had  been  intense, 
ceased,  the  spasms  of  the  limbs  were  stopped,  the  bladder  regained  its 
expulsive  power,  the  bowels  again  began  to  act  without  purgatives  or 
injections  being  required,  and  the  limbs  could  be  moved  as  extensively 
as  the  rigid  contractions  permitted.  These  had  existed  so  long  that  the 
flexor  muscles  had  become  much  shortened,  and  the  skin  in  the  groins 
and  popliteal  spaces  was  tense  and  unyielding.  The  accompanying 
woodcut  (Fig.  ?>l\)  shows  the  positions  of  the  legs  and  arm  at  this  time. 
Under  these  circumstances  I  requested  the  advice  of  my  friend  Prof. 
L.  A.  Sayre,  and  after  consultation  it  was  determined  to  divide  the 
tendons  of  the  tensor  vaginae  femoris,  the  sartorius,  the  gracilis,  and 
the  biceps,  on  each  side.  When  this  was  done  by  Prof.  Sayre,  t In- 
patient being  under  chloroform,  careful  but  powerful  efforts  at  exten- 
sion were  made,  and  the  skin  in  the  popliteal  Bpace  on  both  sides  was 
necessarily  torn,  owing  to  its  contraction  and  inelasticity  ;  the  limbs 
were  thus  brought  into  a  state  of  oomplete  extension,  and,  by  a  Bystem 
of  weights  and  pulleys  similar  to  that  used  in  Buck's  Eracture  apparatus, 
they  were  kept  in  this  position.  The  patient  was,  however,  too  weak 
to  endure  the  fatigue  of  the  necessary  extension  and  confinement.     He 


426 


DISEASES   OF  THE   SPINAL   CORD. 


SPINAL  MENINGITIS.  49? 

took  off  the  weights  whenever  they  caused  pain  or  great  uneasiness. 
To  add  to  the  difficulties,  a  large  bed-sore  formed  on  the  right  buttock, 
and  the  strength  of  the  patient  declined  so  rapidly  that,  in  order  to 
save  his  life,  the  apparatus  had  to  be  entirely  removed.  He  rapidly  re- 
covered, but,  as  cicatrization  went  on,  the  limbs  again  became  con- 
tracted, and  in  the  course  of  two  or  three  months  were  as  bad  as  ever. 
Pain  in  the  back  soon  afterward  supervened,  the  legs  and  one  arm 
began  to  be  affected  with  spasms,  and  the  paralysis  also  returned.  A 
renewal  of  the  former  medication  again  caused  relief,  and  the  patient 
has  to  this  day  remained  free  from  any  spinal  disease,  though  his  legs 
are  still  contracted.  This  is  the  third  case  of  cure  referred  to  as  hap- 
pening in  my  experience. 

For  the  cure  of  the  bed-sores  the  method  recommended  by  Dr. 
Brown-Sequard  may  be  used.  It  consists  in  the  alternate  application 
of  sponges,  one  of  which  is  saturated  with  hot  water  and  the  other  with 
cold  water.  This  should  be  done  for  five  or  ten  minutes  every  day,  and 
the  effect  is  to  increase  the  activity  of  the  circulation  of  the  part,  and 
to  promote  the  formation  of  granulations. 

But  I  have  generally  preferred  the  method  by  galvanism  first  sug- 
gested and  employed  by  Crussel,1  of  St.  Petersburg,  and  which  I  used 
for  the  treatment  of  indolent  ulcers  with  almost  invariable  success,  in 
1859,  when  surgeon  to  the  Baltimore  Infirmary.  The  method  was  also 
recommended  by  Mr.  Spencer  Wells.'1  During  the  last  twelve  years  I 
have  employed  it  to  a  great  extent  in  the  treatment  of  bed-sores  caused 
by  diseases  of  the  spinal  cord,  and  with  scarcely  a  failure — indeed,  I  may 
say  without  any  failure  except  in  two  cases  where  deep  sinuses  had 
formed  which  could  not  be  reached  by  the  apparatus. 

A  thin  silver  plate,  no  thicker  than  a  sheet  of  paper,  is  cut  to  the 
exact  size  and  shape  of  the  bed-sore.  A  zinc  plate  of  about  the  same 
size  is  connected  with  the  silver  plate  by  a  fine  silver  or  copper  wire  six 
or  eight  inches  in  length.  The  silver  plate  is  then  placed  in  immediate 
contact  with  the  bed-sore,  and  the  zinc  plate  on  some  part  of  the  skin 
above — a  piece  of  chamois-skin,  soaked  in  vinegar,  intervening.  This 
must  be  kept  moist,  or  there  is  little  or  no  action  of  the  battery. 
Within  a  few  hours  the  effect  is  perceptible,  and  in  a  day  or  two  the 
cure  is  complete  in  the  great  majority  of  cases.  In  a  few  instances  a 
longer  time  is  required.  I  have  frequently  seen  bed-sores  three  or  four 
inches  in  diameter,  and  half  an  inch  deep,  heal  entirely  over  in  fortv- 
eight  hours.  Mr.  Spencer  Wells  states  that  he  has  often  witnessed 
large  ulcers  covered  with  granulations  within  twenty-four  hours,  and 
completely    Idled    up    and    cicatrization   begun    in    forty-eight    hours. 

1  Yeue  Med.-Chirurg.  Zcitunff,  No.  7,  1847,  p.  235. 

*  "Lectures  on  Electricity  and  Galvanism,"  by  Dr.  Golding  Bird,  London,  1849,  ap- 
pendix. There  is  an  American  edition  of  this  very  iutereating  little  book,  but  it  has  long 
been  out  of  print 


428  DISEASES   OF  THE  SPINAL  CORD. 

During  his  recent  visit  to  this  country  I  informed  him  of  my  experi- 
ence, and  he  reiterated  his  opinion  that  it  was  the  best  of  all  methods 
for  treating  ulcers  of  indolent  character  and  bed-sores. 

Ergot  is  not  so  generally  useful  as  in  congestion,  though  I  rarely 
fail  to  give  it  at  some  time  or  other  in  cases  of  chronic  meningitis,  with 
a  view  to  the  relief  of  the  accompanying  congestion.  Strychnia  is  not 
at  all  admissible  at  any  time.  Reeves '  recommends  it  in  those  cases  in 
which  pains,  cramps,  and  contractions,  are  absent,  but  I  have  never 
seen  such  cases.  Indeed,  a  case  in  which  they  were  not  prominent 
s}'mptoms  could  scarcely  be  regarded  as  one  of  spinal  meningitis. 

In  the  meningitis  and  myelitis  resulting  from  Pott's  disease,  the 
actual  cautery  is  of  inestimable  value.  Its  efficacy  has  been  very 
strongly  insisted  on  by  Charcot  and  Michaud,  both  of  whom  give  cases 
in  illustration  of  its  value.  Within  the  last  year  I  have  treated  five 
cases  of  this  complication  with  the  agent  in  question,  and  with  benefi- 
cial results  in  all.  It  is  an  error  to  suppose  that  the  paraplegia  so  gen- 
erally attendant  in  the  vertebral  disease  is  the  result  of  the  compression 
of  the  cord.  For  there  may  be  paraplegia — as  I  had  the  opportunity  of 
seeing  quite  recently  in  a  case  of  Pott's  disease  under  the  care  of  Dr. 
F.  D.  Lente,  of  Cold  Spring,  and  in  which  I  was  consulted,  when  there 
is  no  deformity  whatever  ;  and  the  paraplegia  may  disappear,  the 
curvature  remaining  undiminished.  This  was  the  case  in  a  patient  sent 
to  me  by  Dr.  Butler,  of  Baltimore,  who  had  been  the  subject  of  Pott's 
disease  several  years  previously,  and  who  had  recovered,  with  very 
great  curvature,  but  without  paralysis.  A  few  weeks,  however,  before 
coming  under  my  observation,  the  paraplegia  had  returned,  the  curva- 
ture remaining  the  same.  Cruveilhier,  as  Charcot  reminds  us,  pointed 
out,  long  ago,  the  fact  that  the  spine  may  be  the  seat  of  the  most  ex- 
traordinary deformities  without  the  cord  being  compressed. 

In  a  lecture  delivered  at  the  Salpetriere,  M.  Charcot a  related  the 
case  of  a  young  Polish  girl  affected  with  Pott's  disease,  complicated 
with  paraplegia,  who  left  Warsaw  to  consult  him,  but  who,  on  her  way 
to  Paris,  stopped  in  Berlin,  to  obtain  Langenbeck's  advice.  The  great 
German  surgeon  counseled  her  not  to  allow  the  cautery  to  be  used, 
but  she,  nevertheless,  proceeded  to  Paris.  After  the  second  cauteriza- 
tion she  walked,  and  fifteen  days  subsequently  she  paid  a  second  visit 
to  Langenbeck,  "furnishing  to  him,"  as  the  reporter  remarks,  "an 
irrefragable  proof  that  empiricism  is  a  good  thing,  when  it  is  accepted 
and  recommended  by  men  of  science." 

The  number  of  cauterizations  need  not  exceed  five  or  six,  and  they 
are  best  made  with  the  disk-ending  iron  with  platinum  tip,  which  should 
be  applied  at  several  points  on  each  side  of  the  diseased  vertebrae. 

1  "  Diseases  of  the  Spinal  Cord  and  its  Membranes,  and  the  Various  Forms  of  Paraly- 
sis arising  therefrom,"  London,  1858,  p.  R5. 

8  Gazettt  Medicale  de  Paris,  5  Decembre.  1874. 


ACUTE   MYELITIS.  429 

CHAPTER  V. 

THE    INFLAMMATIONS    OF    THE    SPINAL    CORD. 

The  subject  of  inflammation  of  the  spinal  cord  has,  within  the  last 
iew  years,  been  so  greatly  amplified  in  all  its  details  by  those  eminent 
French  pathologists,  Charcot  and  Vulpian,  and  their  pupils,  and  so 
much  exact  information  has  been  obtained  through  their  investigations, 
that  the  arrangement  followed  in  the  previous  editions  of  this  work, 
based  on  the  morbid  anatomy,  as  then  known,  no  longer  represents  the 
actual  state  of  the  science.  I  shall,  therefore,  consider  the  inflamma- 
tory affections  of  the  spinal  cord  according  to  a  plan  somewhat  modified 
from  the  systematic  table  of  Clement 1  — a  table  constructed  from  the 
most  recent  data  furnished  by  the  authorities  above  mentioned.  In  so 
doing,  I  shall  omit  those  disorders  which  have  only  a  theoretical  exist- 
ence, or  which,  in  my  opinion,  have  been,  on  insufficient  data,  assigned 
a  definite  patho-anatomical  position. 

I. 

ACUTE   MYELITIS. 

a.  Acute   General  Myelitis. 

In  acute  general  myelitis  the  whole  extent  of  the  cord  is  involved 
in  the  morbid  process. 

Symptoms. — The  onset  of  the  disease  is  sudden.  A  chill  is  generally 
the  first  symptom  observed,  and  this  is  followed  immediately  by  high 
febrile  excitement,  during  which  the  pulse  may  be  as  frequent  as  160 
per  minute.  The  temperature  of  the  body  is  slightly  elevated,  but 
rarely  reaches  103°Fahr.  Alterations  of  sensibility  and  motility  are 
noticed  with  the  inception  of  the  fever. 

Among  the  first,  pain  in  the  back  is  prominent.  This  is  usually 
most  severe  in  the  dorsal  region,  and  is  aggravated  by  percussion  and 
by  the  passage  of  a  sponge  saturated  with  hot  water,  or  one  with  cold 
water,  over  the  affected  region.  It  is  not,  however,  so  intense  in  char- 
acter as  that  attendant  on  acute  spinal  meningitis,  and  it  is  not  in- 
creased by  movements  of  the  limbs  or  of  the  vertebral  column,  in  which 
respects  it  differs  from  the  pain  due  to  this  last-named  disease. 

In  addition,  there  are  various  derangements  of  the  cutaneous  sensi- 
bility in  those  parts  of  the  skin  below  the  seat  of  the  disease.  These 
consist  of  formication,  "pins  and  needles,"  a  sensation  as  if  water  were 
trickling  over  the  skin,  as  if  the  limb  were  asleep,  and  of  sensations  of 
cold  or  heat.  .\n:esthesia  is  the  most  common  general  condition  of  the 
skin,  and  it  is  often  accompanied  with  cutaneous  pains,  which  are  the 

•  "  Note  sur  les  myeMites  d'apris  lea  travaux  frimjais  r6cciits,"  Paris,  1875,  p.  1 


430  DISEASES   OF   TEE   SPINAL   CORD. 

more  intense  the  more  profound  is  the  anaesthesia.  Thus,  if  we  have 
ascertained  that  the  cutaneous  sensibility  is  very  much  impaired  at  a 
particular  spot,  we  will  frequently  find  this  spot  the  seat  of  severe  and 
spontaneous  pains.  In  such  cases,  too,  a  prick  with  a  pin  is  felt,  but 
the  ability  to  distinguish  the  two  points  of  the  assthesiometer  is  lost, 
even  when  they  are  widely  separated.  Indeed,  they  may  not  be  felt  at 
all  unless  they  are  so  used  as  to  cause  pain.  I  have  several  times  ob- 
served patients  whose  tactile  sensibility  was  almost  entirely  gone,  but 
whose  sensibility  to  pain  was  so  great  that  they  could  not  endure  the 
contact  of  the  bedclothes.  The  distinction,  therefore,  between  insensi- 
bility to  touch — generally  called  anaesthesia — and  insensibility  to  pain 
— analgesia — must  be  clearly  made. 

A  sensation  of  constriction  around  the  body  is  sometimes  experi- 
enced, and  the  limbs  are  likewise  often  the  seat  of  a  like  symptom, 
giving  the  impression  to  the  patient  that  they  are  encircled  by  tight 
cords  or  incased  in  closely-fitting  armor. 

Hyperesthesia  is  occasionally  present,  but  probably  not  unless  there 
is  meningitis  associated  with  the  myelitis. 

Motility  is  affected  at  a  very  early  period  of  the  disease,  and  at  first 
consists  of  simple  twitchings  of  the  muscles,  and  paralysis.  The  latter 
comes  on  with  great  rapidity,  and  may  become  complete  in  a  few  hours. 
Jaccoud  '  states  that  he  has  seen  this  result  produced  in  thirty-six  hours, 
and  Ollivier2  cites  several  cases  to  the  same  effect.  The  bladder  is 
almost  invariably  paralyzed,  as  are  also  its  sphincter  and  that  of  the 
anus.  There  is,  therefore,  dribbling  of  the  urine,  and  the  fasces  are 
evacuated  involuntarily  as  soon  as  they  pass  into  the  rectum. 

Reflex  excitability  is  entirely  abolished  in  acute  general  myelitis. 
Tickling  the  sole  of  the  foot,  therefore,  fails  to  produce  any  movement. 

Electro-muscular  contractility  is  diminished,  unless,  perhaps,  in  the 
very  earliest  stage  of  the  affection,  and  the  "reactions  of  degenera- 
tion" are  well  marked.  There  is  always  a  tendency  to  rapid  atrophy 
of  the  paralyzed  muscles. 

The  temperature  of  the  affected  limbs  begins  to  fall  from  the  very 
first,  and  may  be  diminished  by  as  much  as  3°  Fahr.  Sloughs  and  bed- 
sores make  their  appearance  about  the  sixth  day,  though  I  have  several 
times  seen  them  form  at  a  much  earlier  period.  Although  they  occur 
in  those  parts  of  the  body — as  the  sacrum,  nates,  and  hips — which  are 
subject  to  pressure,  it  is  very  certain  that  the  decubitus  is  not  their 
primary  cause.  In  three  instances  I  have  had  them  result,  in  cases  under 
my  charge,  within  twenty-four  hours  after  the  inception  of  the  disease. 

Besides  the  foregoing  symptoms,  there  are  others  referable  to  the 
viscera,  and  which  may  occur  almost  simultaneously,  or  in  marked 
sequence,  as  the  morbid  process  extends  through  the  length  of  the 

1  Op.  tit.,  p.  318. 

2  Op.  tit.,  chap,  huitieme,  "  Mydlite,  ou  inflammation  dc  la  moelle  6pinifere." 


ACUTE   MYELITIS.  431 

cord.  Thus,  there  may  be  frequent  and  almost  constant  painful  erec- 
tions, vomiting,  derangement  of  the  liver,  irregular  action  of  the  heart, 
difficult  respiration,  and  more  or  less  impairment  of  the  faculty  of  swal- 
lowing. The  voice  may  be  abolished,  and  the  muscles  of  articulation 
be  so  far  paralyzed  as  to  render  even  a  whisper  impossible. 

The  urine  is  often,  if  not  invariably,  alkaline.  This  is  not  the  result 
of  contact  with  the  mucus  retained  in  the  paralyzed  bladder,  for,  if  this 
organ  be  thoroughly  cleansed  with  water,  the  urine  collected  from  it 
with  a  catheter  is  found  to  be  of  alkaline  reaction.  This  alkalinity  is 
doubtless  due  to  the  presence  of  an  excessive  proportion  of  the  amrno- 
nio-magnesian  phosphates. 

The  quantity  of  urine  is  diminished,  and  albumen,  pus,  or  blood,  may 
be  present  in  it,  besides  the  large  amount  of  vesical  mucus  which  is  so 
prominent  a  constituent. 

Acute  general  myelitis  ordinarily  runs  its  course  in  about  ten  days, 
though  it  may  terminate  in  death  in  a  much  shorter  period,  or  be  pro- 
longed for  several  weeks.  Death  is  due  either  to  asphyxia  or  exhaus- 
tion. The  former  result  is  obtained  when  the  inflammation  reaches  the 
upper  cervical  region,  and  the  muscles  of  respiration  become  paralyzed, 
or  the  action  of  the  heart  greatly  interfered  with.  In  consequence  of 
the  paralysis  of  these  muscles  and  of  those  concerned  in  deglutition, 
mucus  accumulates  in  the  air-passages  and  pharynx,  and  may  lead  to 
sudden  asphyxia. 

Such  is  a  general  view  of  the  symptomatology  of  acute  general 
myelitis,  when  the  whole  or  greater  part  of  the  spinal  cord  is  involved. 
It  is  not,  however,  to  be  supposed  that  the  phenomena  are  all  present 
at  the  same  time.  Such  a  condition  very  rarely  exists.  As  a  rule,  the 
inflammation  advances  from  below  upward,  and  the  symptoms  occur  in 
order  as  the  morbid  action  progresses.  Sometimes,  however,  the  cen- 
tral region  of  the  cord  is  first  attacked,  and  the  extension  takes  place 
in  both  directions. 

h.  Acute  Partial  Myelitis. 

In  this  form  of  the  affection  the  inflammation  is  restricted  to  a 
limited  portion  of  the  cord,  and,  as  a  consequence,  the  symptoms  are 
less  profound  and  extensive  than  in  the  general  form.  The  morbid 
process  may  be  confined  to  a  very  small  part  of  the  cord,  or  may  involve 
i  he  cervical,  dorsal,  or  lumbar  regions,  with,  of  course,  some  variation  in 
tin;  Bymptoms,  according  to  the  situation. 

Symptoms. — The  pain  in  the  back  is  similar  to  that  experienced  in 
the  general  form,  and  it  is,  like  that,  excited  or  aggravated  by  percus- 
sion or  by  the  passage  of  a  sponge  saturated  with  very  hot  or  cold  water 
over  the  affected  locality. 

The  aberrations  of  sensibility  are  less  strongly  marked,  but,  on  ac- 
count of -the  slower  progress  of  the  disease,  they  are  of  longer  duration 


432  DISEASES  OF  THE  SPINAL  CORD. 

In  a  case  now  under  my  charge,  and  in  which  there  is  the  pain  in  the 
spine,  presenting  the  above-mentioned  characteristics,  the  patient,  a 
gentleman  about  thirty  years  of  age,  has,  in  addition  to  these  marked 
symptoms,  nearly  absolute  anaesthesia  in  the  left  lower  extremity, 
which  existed  as  the  only  phenomenon  of  any  moment  for  three  or  four 
weeks. 

The  sense  of  constriction  around  the  body  is  generally  but  not 
always  present,  and  its  seat  marks  the  upper  limit  of  the  inflammation. 

Another  symptom,  often  noticed,  is  one  to  which  Charcot  has  called 
special  attention,  and  that  is,  .the  inability  of  the  patient  to  localize  his 
sensations.  Sometimes  this  is  surprisingly  manifested.  In  a  patient 
whom  I  brought  at  my  clinique  before  the  class  of  the  University  Med- 
ical College,  a  prick  of  a  pin  made  in  the  right  thigh  was  referred  to 
the  left  thigh,  and  one  made  on  the  left  foot  was  felt  on  the  left  knee. 
So  far  as  the  intensity  of  the  sensation  was  concerned,  it  was  as  great 
as,  if  not  greater  than,  in  health.  This  is  not  an  unusual  circumstance. 
In  a  case  cited  by  Charcot,1  the  sensibility  to  cold,  to  contact,  and  to 
tickling,  was  abolished,  and  yet,  when  the  patient  was  pinched,  an 
acute  sensation  of  pain  was  experienced.  This  pain  was  accompanied 
by  spinal  symptoms  : 

1.  There  was  error  as  regarded  location:  the  leg  was  pinched,  but  the 
pain  was  referred  to  the  hip,  then  to  the  opposite  hip,  and,  finally,  to  the 
whole  length  of  both  limbs. 

2.  The  sensation  was  assimilated  to  a  vibration  or  a  trembling. 

3.  It  was  the  same  for  the  different  methods  of  excitation  ;  it  not 
only  ensued  on  pinching,  but  on  the  application  of  cold. 

4.  It  lasted  during  a  quarter  of  an  hour,  and  sometimes  longer. 

5.  Sometimes  it  was  not  perceived  till  an  appreciable  interval  of 
time  had  elapsed.  In  a  case  cited  by  Romberg,  this  interval  was  thirty 
seconds.2 

As  Charcot  says,  this  delay  in  appreciating  sensations  is  due  to  a 
profound  lesion  of  the  gray  substance  of  the  cord. 

The  paralysis  of  motion  observed  in  partial  acute  myelitis  is  less 
extensive  than  that  which  exists  in  the  general  form  of  the  disease.  In 
the  early  stages  there  are  convulsive  movements  in  the  muscles  sup- 
plied by  the  nerves,  having  their  origin  in  the  affected  portion  of  the 
cord;  but,  eventually,  the  loss  of  power  becomes  more  or  less  complete. 
It  may  at  no  time,  if  the  lesion  be  very  circumscribed,  extend  beyond 
the  point  of  slight  diminution. 

The  reflex  excitability  is  generally  augmented.  In  a  case  now  under 
my  charge,  in  which  the  morbid  process  apparently  only  involves  a  seg- 
ment of  the  cord  in  the  lower  dorsal  region,  the  slightest  touch  of  the 

1  Dujardin-Beaumetz,  "  De  la  myelite  aigue,"  Paris,  1872,  p.  121. 
*  In  a  case  of  locomotor  ataxia  under  my  own  care,  to  be  cited  more  particularly 
farther  on,  this  retardation  amounted  to  several  minutes. 


ACUTE   MYELITIS.  433 

lower  extremities  is  followed  by  movements  as  intense  as  those  in 
tetanus.  Charcot,  as  stated  by  Dujardin-Beaumetz,  arranges  the  phe- 
nomena under  this  head  into  two  classes  :  that  in  which  there  is  a 
simple  exaggeration  of  the  spinal  excitability,  and  that  in  which  there 
is  the  continuance  of  the  spasms,  which  are,  in  my  opinion,  improperly 
designated  spinal  epilepsy.  This  spinal  epilepsy  may  appear  under 
two  forms  :  either  as  tetaniform  or  tonic  convulsions,  or  as  saltatory 
cramps — clonic  convulsions.  In  several  cases  I  have  witnessed  both  of 
these  types  in  the  same  individual. 

It  is  not  often  the  case  that  bed-sores,  or  other  forms  of  ulceration 
and  death  of  the  soft  parts,  occur  in  acute  partial  myelitis,  except  in 
those  cases  which  have  a  traumatic  origin — they  are  generally  rapidly 
developed.  It  is  not  uncommon,  however,  to  witness  atrophy  of  the 
paralyzed  muscles,  more  or  less  extensive  and  complete,  according  to 
the  extent  and  profundity  of  the  lesion  of  the  cord. 

The  temperature  of  the  parts  supplied  by  the  nerves  coming  from 
the  affected  region  of  the  cord  is,  perhaps,  in  the  first  place,  somewhat 
increased.  Eventually,  however,  as  the  paralysis  of  sensibility  and  mo- 
tion becomes  more  strongly  marked,  there  is  a  decided  fall.  By  means 
of  Dr.  Lombard's  thermo-electric  differential  calorimeter,  comparative 
results  can  be  simultaneously  obtained  with  great  ease  and  exactness. 

The  electric  excitability  of  the  paralyzed  parts  is  always  lessened. 

The  symptoms  of  acute  partial  myelitis  are,  of  course,  different,  ac- 
cording as  the  cervical,  dorsal,  or  lumbar  region,  is  the  seat  of  the  mor- 
bid action.  For  convenience  of  description,  the  cord  may  be  divided 
into  two  parts  :  the  cervico-dorsal,  embracing  the  cervical  region  and 
the  dorsal  as  far  as  the  sixth  dorsal  vertebra  ;  and  the  lumbo-dorsal, 
comprehending  the  remaining  part  of  the  cord. 

When  the  lesion  involves  the  cervico-dorsal  region,  the  upper  ex- 
tremities may  be  paralyzed  without  the  lower  participating;  but  dis- 
turbances of  sensibility  are  generally  experienced  in  all  parts  situated 
below  the  seat  of  disease.  If  the  upper  part  of  this  division  be  affected 
there  are  difficulty  of  swallowing,  disturbances  of  the  respiration  and 
circulation,  and  gastric  derangement.  The  pupils  are  at  first  dilated, 
and  subsequently  contracted.  Epileptic  convulsions  are  occasionally  an 
accompaniment.  There  may  be,  as  I  have  seen  in  two  cases,  accessions 
of  great  venereal  excitement. 

When  (he  dorso-lumbar  region  is  the  part  affected,  the  lower  ex- 
tremities alone  exhibit  aberrations  of  Sensibility  and  motility.  The 
sense  of  constriction  is  generally  felt,  and  the  bladder  and  rectum  are 
usually  paralyzed. 

Acute  partial  myelitis  is  much  slower  in  its  progress  than  the  gen- 
eral form  of  the  disease,  and  life  may  be  prolonged  tor  a  considerable 
period  if  the  lesion  be  not  very  extensive. 

Causes. — Acute  myelitis,  whet  her  of  the  general  or  partial  form,  Ls 
2  \) 


434  DISEASES  OF  THE  SPINAL  CORD. 

more  frequently  the  result  of  injury  than  of  any  other  cause.  It  is 
likewise  a  sequence  of  disease  of  the  vertebrae,  extending  to  the  dura 
mater  and  other  membranes,  and  of  meningitis.  It  is  also  said  to  be 
produced  by  exposure  to  extreme  heat  or  cold,  by  violent  muscular 
efforts,  and  by  venereal  excesses.  Twelve  cases  have  come  under  my 
observation.  Of  these,  three  were  the  result  of  wounds,  two  ensued  on 
disease  of  the  vertebrae,  three  on  exposure  to  intense  cold,  two  were 
apparently  due  to  excessive  muscular  exertion,  and  two  were  caused  by 
extension  of  acute  meningitis. 

Diagnosis. — The  principal  diagnostic  marks  of  acute  myelitis  are 
the  occurrence  of  the  sensation  of  constriction  around  the  body,  the 
alkalinity  of  the  urine,  the  rapid  supervention  and  the  completeness 
of  the  paralysis,  the  great  predisposition  to  sloughs  wherever  there  is 
the  least  pressure,  the  excitation  of  pain  in  one  part  of  the  body  by 
irritation  applied  to  some  other  part,  the  causation  of  reflex  movements 
in  a  similar  way,  the  speedy  loss  of  electric  contractility,  and  the 
marked  depression  of  temperature  in  the  paralyzed  parts. 

From  acute  meningitis  it  is  distinguished  by  the  fact  that  the  pain 
in  this  disease  is  more  severe,  that  it  is  aggravated  by  movements  of 
the  spine,  and  that  there  are  marked,  and  sometimes  permanent,  con- 
tractions of  the  limbs.  The  paralysis  is  never  so  profound.  Moreover, 
bed-sores  and  atrophies  are  not  phenomena  met  with,  except  as  the 
results  of  long-continued  pressure  in  the  one  case  and  of  disuse  in  the 
other. 

In  congestion  of  the  cord  the  symptoms  are  less  strongly  pro- 
nounced, and  are  more  or  less  subject  to  remissions  ;  bed-sores  are  un- 
common ;  the  progress  of  the  disease  is  slower,  and  the  symptoms  are 
aggravated  when  the  patient  assumes  the  recumbent  posture,  and  the 
urine  is  not  alkaline,  except  as  the  consequence  of  paralysis  of  the 
bladder. 

From  haemorrhage  of  the  cord  the  diagnosis  is  not,  in  general,  a 
matter  of  doubt,  but  the  following  case,  reported  by  Dujardin-Beau- 
metz,  would  seem  to  present  an  exception  to  this  statement  : 

"A  porter,  while  at  his  work,  was  suddenly  seized  with  complete 
paralysis  of  motion  and  sensibility  of  all  parts  of  his  body,  except  the 
head  and  neck.  There  was  no  loss  of  consciousness.  The  bladder  and 
rectum  were  paralyzed  ;  there  were  no  contractions  ;  the  respiration 
was  slow  and  painful,  the  diaphragm  alone,  of  all  the  respiratory  mus- 
cles, being  active.  The  intelligence  was  perfect.  The  diagnosis  was 
haemorrhage  of  the  cord  at  about  the  junction  of  the  cervical  with  the 
dorsal  portion.  Three  days  after  the  accession  the  patient  died  as- 
phyxiated. On  post-mortem  examination,  no  trace  of  haemorrhage 
could  be  found,  but  the  cord  was  softened  and  completely  broken  up  at 
the  dorsal  enlargement." 

The  diagnosis  from  hysteria  may  sometimes  require  to  be  made. 


ACUTE  MYELITIS.  435 

As  is  well  known,  this  condition  may  simulate  almost  every  affection  of 
the  nervous  system,  and  acute  inflammation  of  the  cord  is  not  one  of 
the  exceptions.  The  pain  in  the  back,  the  constriction  around  the 
body,  the  paraplegia,  the  cystic  and  rectal  derangements,  the  anaes- 
thesia as  met  with  in  acute  myelitis,  may  all  be  due  to  hysteria.  But 
careful  examination  will  serve  to  make  the  discrimination  easy  and 
complete.  The  symptoms  are  exaggerated,  and  are  not  constant,  the 
general  disturbance  of  the  system  is  slight,  there  is  no  progressive  ad- 
vance of  the  disease,  and  the  patient,  nearly  always  of  the  female  sex, 
exhibits  the  history  and  diathesis  of  hysteria  so  unmistakably,  that 
error  is  rendered  almost  out  of  the  question. 

Prognosis. — The  termination  of  general  acute  myelitis  is  in  death 
sooner  or  later.  Even  if  it  passes  into  the  chronic  stage,  the  altera- 
tions in  the  structure  of  the  cord  are  so  extensive  as  to  be  incompatible 
with  the  performance  of  its  functions.  Death  was  the  result  in  all 
the  cases  that  I  have  personally  observed,  and  this  event  occurred  in  all 
within  three  weeks. 

In  partial  acute  myelitis  recovery  is  not  impossible,  although  even 
in  this  form  the  prognosis  is  grave,  and  the  life  of  the  patient,  if  saved, 
is  always  at  the  expense  of  the  sensibility  and  motility  of  the  parts 
below  the  seat  of  the  lesion. 

Even  then,  in  many  cases,  disease  of  the  bladder,  and  other  second- 
ary affections  shorten  the  term  of  existence. 

Morbid  Anatomy  and  Pathology.— In  acute  general  myelitis  the 
whole  cord  is  involved  in  the  morbid  action,  and  exhibits  a  more  or  less 
considerable  enlargement  throughout  its  entire  length.  As  both  the 
white  and  gray  substances  are  implicated,  both  become  broken  down  by 
softening,  and  hence  it  is  impossible  to  distinguish  one  from  the  other. 
It  appears,  however,  to  be  extremely  probable  that  originally  the  mor- 
bid process  is  parenchymatous,  that  is,  confined  to  the  true  cell-ele- 
ments of  the  cord,  and  that  the  neuroglia  is  subsequently  attacked. 
Extravasations  of  blood  are  met  with  throughout  the  medullary  tissue. 
The  membranes  are  sometimes  adherent  to  the  cord  at  various  points, 
or  there  may  be  puriform  accumulations  between  them  and  the  cord. 
At  other  times  the  pus  is  found  in  isolated  depots  or  in  canals  extend- 
ing through  the  entire  length  of  the  nerve-substance.  The  tendency 
is  to  a  still  more  decided  condition  of  softening,  and  eventually  a  stage 
is  reached  in  which  the  cord  is  reduced  to  a  semi-liquid  state. 

The  inflammation  in  cases  of  acute  partial  myelitis  may  be  limited 
to  the  white  substance  or  to  the  gray  substance,  or  may  attack  both 
these  tissues.  It  may  likewise  affect  the  antero-lateral  columns,  tlie 
posterior,  or  extend  to  both.  Undoubtedly,  it'  we  had  sufficient  oppor- 
tunities to  witness  cases  of  spontaneous  origin  not  the  result  of  trau- 
matic causes,  or  of  the  extension  of  other  diseases,  we  should  be  enabled 
to  distinguish  by  the  symptoms  which  part  of  the  cord  histologically  01 


436  DISEASES  OF  THE  SPINAL  CORD. 

topographically  is  affected.  For  there  can  be  no  doubt  that,  as  in 
anaemia,  or  as  we  shall  see  hereafter  in  certain  acute  and  chronic  forms 
of  myelitis,  the  symptoms  must  be  as  characteristic  as  are  the  functions 
of  the  several  histological  and  regional  parts  of  the  cord. 

As  regards  the  obvious  morbid  anatomical  features,  we  find  that 
when  the  lesion  is  situated  in  the  white  substance  the  membranes  of 
the  affected  portion  are  congested,  thickened,  opaque  in  patches,  and 
adherent  to  the  cord.  The  cord  is  softened  to  a  variable  depth,  and 
this  portion  is  detached  with  the  membranes  if  these  be  removed.  This 
softened  portion  is  in  the  early  stage  rose-colored  and  studded  with  red 
points,  marking  the  situation  of  the  enlarged  blood-vessels.  As  the 
disease  advances,  the  color  deepens  to  a  reddish-brown,  then  begins  to 
get  lighter,  and,  passing  through  several  shades  of  yellow,  eventually 
becomes  white. 

When  the  gray  substance  is  involved,  the  changes  in  its  physical 
appearance  are  similar  ;  and,  when  both  the  white  and  the  gray  are  the 
seat  of  the  morbid  process,  it  is  impossible  to  distinguish  the  two  sub- 
stances from  each  other. 

Microscopical  examination  shows  the  existence  of  congestion,  and, 
as  an  essential  feature,  an  increase  in  the  amount  of  connective  tissue 
or  neuroglia  of  the  cord.  The  evidences  of  this  hypertrophy  are  seen 
in  the  increase  of  fusiform  cells  and  in  the  production  of  multinuclear 
cells  and  free  nuclei.  These  formations  take  place  at  the  expense  of 
the  proper  nervous  tissue  of  the  cord,  the  anatomical  elements  of  which 
undergo  atrophy  and  fatty  degeneration.  The  nervous  tubule's  are  thus 
often  disintegrated  and  their  contents  disseminated  through  the  extra- 
neous tissue.  The  axis  cylinders  are  entirely  surrounded  by  oil-glob- 
ules, or  are  altogether  broken  up  and  rendered  unrecognizable. 

Should  suppuration  occur,  the  elements  of  pus  are  observed  among 
those  already  described,  and  take  their  place  to  a  considerable  extent. 

In  case  of  the  passage  of  acute  myelitis  into  the  chronic  form,  the 
centre  of  inflammation  usually  undergoes  other  changes,  which,  how- 
ever, still  maintain  the  general  characteristic  of  hypertrophy  of  the 
neuroglia  at  the  expense  of  the  proper  nervous  tissue.  Induration,  or, 
as  it  is  now  generally  called,  sclerosis,  is  the  result.  Occasionally,  how- 
ever, the  softening  persists  and  becomes  the  permanent  structural  con- 
dition of  the  diseased  portion  of  the  cord. 

When  the  lesion  is  in  the  gray  substance,  the  microscope  shows  the 
nervous  cells  to  be  broken  up,  and  the  anatomical  elements  of  the  blood 
to  be  scattered  through  the  tissue. 

Treatment. — The  treatment  of  acute  general  myelitis  offers  no  en- 
couraging features.  The  most  that  can  be  done  is  to  endeavor  to 
prevent,  as  far  as  possible,  the  formation  of  sloughs,  by  placing  the 
patient  on  a  water-bed,  and  by  sponging  the  parts  exposed  to  pressure, 
with  whiskey  or  with  hot  and  cold  water  alternately  applied.    The  treat- 


ACCTE   MYELITIS.  437 

mont  generally  does  not  differ  from  that  recommended  in  acute  menin- 
gitis, the  indications  being  almost  identical.  So  far  ~.s  my  experience 
extends  I  have  never  found  any  means  sufficient  for  cure,  anu  the  few 
successful  instances  that  have  been  reported  are  doubtless,  as  JaccouU 
suggests,  cases  of  congestion  or  meningitis. 

But  in  the  partial  form  of  the  disease  there  is  some  hope  of  being 
able  to  arrest  the  morbid  process,  or  at  least  to  prevent  its  extension  to 
the  sound  parts  of  the  cord.  Some  authors  have  recommended  mer- 
curials, but  I  do  not  perceive  any  indication  for  their  use.  I  am  satis- 
fied, however,  that  I  have  derived  decided  benefit  from  the  administra- 
tion of  ergot  in  large  doses,  as  recommended  for  congestion,  and  from 
the  employment  of  revulsives.  Of  these  latter  agents  the  actual  cautery 
occupies  the  first  place.  It  should  be  applied  either  in  the  form  of 
longitudinal  lines  on  each  side  of  the  vertebral  column  at  the  seat  of 
the  lesion,  or  as  points,  to  the  number  of  three  or  four,  similarly  situated. 
The  skin  should  be  rendered  anaesthetic  by  the  ether-spray  before  the 
application  of  the  heated  metal,  and  this  latter  should  be  platinum, 
brought  to  a  white  heat. 

By  this  agent,  in  conjunction  with  the  ergot,  I  have  recently,  in  the 
case  of  a  carpenter  presenting  all  the  symptoms  of  acute  partial  myeli- 
tis involving  the  lower  dorsal  region  of  the  cord,  succeeded  in  effecting 
such  a  mitigation  of  the  disease  as  to  arrest  its  onward  progress,  and 
restore  motion  and  sensibility  to  the  paralyzed  limbs  to  quite  an  ap- 
preciable extent.  The  ergot  was  administered  in  doses  of  a  drachm 
every  two  hours  for  five  days.  Two  cauterizations  were  made  during 
this  period.  During  the  ensuing  thirty  days  the  ergot  was  given  in 
similar  doses  three  times  daily,  and  two  additional  cauterizations  were 
performed.  The  patient  was  then  left  without  further  medical  interfer- 
ence, being  able  to  move  his  legs,  to  pass  and  retain  his  urine,  and  to 
feel  impressions  made  on  the  skin  below  the  seat  of  the  disease.  While 
complete  recovery  will  not  probably  result,  I  am  quite  satisfied  that  life 
was  saved  by  the  action  of  the  agents  in  question. 

II. 

INFLAMMATION   LIMITED   TO   THE   ANTERIOR   TRACT   OF    GRAY    MATTER    OF 

THE    SPINAL   CORD. 

I  have  preferred  to  include  the  diseases  next  to  be  considered, 
under  the  title  above  given,  in  preference  to  others  which  have 
been  brought  forward.  Tims  the,  term  "anterior  horns  of  gray  mat- 
ter'''' would  not  apply  to  the  medulla  oblongata,  and  that  of  "motor 
tract"  employed  by  Dr.  E.  S.  Seguin,1  does  not  accord  with  the  vi->\vs 
I  '•ntertain  relative  to  the  physiological  anatomy  of  the  region  referred 
to,  it  being,  in  my  opinion,  trophic  as  well  as  motor  in  function.  The 
1  "Spinal  Paralysis  of  the  Adult,"  etc.,  New  York,  1871. 


438  DISEASES   OF   THE   SPINAL   CORD. 

term  " anterior  tract  of  gray  matter''''  is  not  only  sufficiently  precise 
as  regards  the  spinal  cord  proper,  but  it  can  logically  be  applied  to 
the  corresponding  mass  of  ganglionic  tissue  in  the  medulla  oblongata, 
and  at  the  same  time  does  not  commit  us  in  advance  to  any  views 
relative  to  the  office  of  this  gray  matter  as  a  nerve-centre. 

In  inflammation  limited  to  the  anterior  tract  of  gray  matter  of  the 
spinal  cord,  including  the  medulla  oblongata,  the  morbid  process  may 
involve  both  the  motor  and  trophic  cells — that  is,  all  the  nervous  ele- 
ments of  which  the  tissue  is  composed — or  it  may  be  restricted  on 
the  one  part  to  the  motor  cells,  and  on  the  other  to  the  trophic  cells. 

There  are,  thus,  three  categories  of  diseases  to  be  considered  under 
the  general  head  of  inflammation  limited  to  the  Anterior  Tract  of  Gray 
Matter  of  the  Spinal  Cord,  viz.: 

1.  Inflammation  of  motor  and  trophic  nerve-cells  :  a.  Infantile 
spinal  paralysis,     b.  Spinal  paralysis  of  adults. 

2.  Inflammation  of  the  motor-cells  :  a.  Glosso-labio-laryngeal  pa- 
ralysis. 

3.  Inflammation  of  the  trophic  cells  :  a.  Progressive  muscular 
atrophy,     b.  Progressive  facial  atrophy. 

In  addition  to  these  primary  affections,  there  are  others  in  which 
the  anterior  tract  of  gray  matter  is  involved  secondarily,  or  at  least  in 
conjunction  with  inflammation  of  the  white  substance,  entering  into 
the  composition  of  the  antero-lateral  columns  of  the  cord.  These  will 
be  considered  under  another  head. 

1.  Inflammation  of  Motor  and  Trophic  Nerve- Cells. 

All  the  diseases  of  this  class  are  characterized  by  two  essential  phe- 
nomena, paralysis  and  atrophy.  The  paralysis  is  the  first  of  these  symp- 
toms to  make  its  appearance,  the  atrophy  following  more  or  less  closely, 
and  ensuing  not  as  a  consequence  of  paralysis  and  disuse,  but  as  an  active 
pathological  condition.  The  chief  reasons,  as  we  shall  see  hereafter,  for 
the  theory  of  the  existence  of  trophic  cells  in  the  spinal  cord,  are  found 
in  the  facts  that  the  atrophy  is  an  independent  feature  of  the  diseases 
of  the  class  under  notice,  and  that  it  may  exist  without  paralysis  at 
all,  except  in  so  far  as  an  atrophied  muscle  is  necessarily  weaker  than 
one  not  so  affected  ;  and,  again,  that  paralysis  may  exist  without  atro- 
phy, and  the  gray  matter  of  the  anterior  tract  alone  be  involved. 

a.   Infantile  Spinal  Paralysis — Organic  Infantile  Paralysis — 
Anterior  Polip-myelitis. 

Under  the  name  of  organic  infantile  paralysis — to  which  term,  now 
that  the  morbid  anatomy  is  well  understood,  that  of  infantile  spinal 
paralysis  is  to  be  preferred — I  have  considered  at  length '  a  form  of 

1  Journal  of  Psychological  Medicine,  No.  1,  1867,  p.  49.  Also,  my  translation  of 
Meyer's  "  Electricity  in  its  Relations  to  Practical  Medicine,"  New  York,  1870,  p.  228,  note. 


INFANTILE   SPINAL  PARALYSIS.  439 

parnlysis  occurring  in  young  children,  previously  described  by  Heine,1 
who  was  the  first  to  direct  special  attention  to  it  under  the  name  used 
at  the  head  of  this  section  ;  by  Rilliet2  and  Barthez  as  the  paralysie 
essentielle  deVenfance,  and  by  Duchenne 3  as  paralysie  atrqphique  gi'ais- 
seicse  de  Venfance.  Previous  to  the  writings  of  these  authors,  the  affec- 
tion in  question  was  not  distinctly  recognized  as  a  separate  disease,  but 
was  confounded  with  a  much  less  serious  disorder,  probably  belonging  to 
the  class  already  considered  under  the  head  of  anaemia  of  the  anterior 
columns  of  the  spinal  cord.  The  tendency  in  the  present  affection  to 
muscular  atrophy,  and  the  permanent  character  of  the  paralysis,  are 
phenomena  which  sufficiently  distinguish  it  from  the  temporary  paraly- 
sis referred  to. 

Symptoms. — The  beginning  of  infantile  spinal  paralysis  is  generally 
indicated  by  febrile  excitement,  convulsions,  and  pain  in  the  back.  This 
pain  marks  the  seat  of  the  disease  in  the  spinal  cord  to  which  the  paraly- 
sis of  the  muscles  is  due.  These  symptoms  last  for  a  few  days,  or  they 
may  be  so  slight  as  in  very  young  children  not  to  attract  attention;  or, 
again,  they  may  be  absent  altogether. 

Sometimes  the  paralysis  is  readily  observed  from  the  first,  both  by 
its  extent  and  intensity;  at  others,  it  is  not  perceived  till  some  one 
notices  that  the  child  does  not  use  one  hand  or  kick  with  one  leg.  The 
age  of  the  patient,  of  course,  exercises  considerable  influence  on  the 
question  of  ascertaining  the  existence  of  the  paralysis  at  an  early 
period.  All  four  of  the  limbs  may  be  affected,  or  the  paralysis  may  be 
restricted  to  the  legs,  or  more  rarely  to  the  arms,  or  to  one  arm  and 
one  leg  of  the  same  side,  or  of  opposite  sides,  or  to  one  leg  or  one  arm, 
or  even  to  a  group  of  muscles  or  a  single  muscle. 

The  temperature  of  the  affected  limbs  is  always  much  lower  than 
that  of  the  corresponding  sound  ones.  The  difference  is  sometimes  as 
much  as  eight  or  ten  degrees,  though  generally  it  is  not  more  than  five. 
If,  spontaneously  or  under  appropriate  treatment,  amendment  takes 
place,  the  first  indication  is  shown  by  the  return  of  the  temperature 
toward  the  natural  standard.  It  thus  becomes  important  to  have  some 
means  by  which  a  very  slighl  increase  of  heat  may  be  noticed.  A  deli- 
cate thermometer  graduated  to  tenths  of  a  degree  will  generally  suffice, 
but  much  more  exact  indications  may  be  obtained  by  Lombard's  thermo- 
electric differential  calorimeter,  described  in  the  introduction  to  this 
treatise.     One  of  the  thermo-electric  piles  is  placed  on  the  sound  limb, 

1  "  Beobachtungen  fiber  L&hmungszust&nde  der  untera  Extremitaten  und  deren  Be- 
bandlung,"  Stuttgart,  L840;  and  " Spinale  Kinderlahmung,"  zweite  Auflage,  Stuttgart, 
I860. 

2"Trait('',  clinique  el  pratique,  dea  maladies  <1<-  I'enfanoe,"  Pari-,  18">:'.,  tome  ii., 

iff  hebdomadaire,   1845,  and  "Traits  de  1' electrisation  localisee,"  1*  Edition, 
Paris,  1855. 


440  DISEASES   OF   THE   SPIRAL   CORD. 

the  other  on  the  corresponding  part  of  the  paralyzed  limb.  Both  are 
in  connection,  by  delicate  silk-covered  wire,  with  the  poles  of  a  gal- 
vanometer. If  the  temperature  of  both  limbs  be  the  same,  the  needle 
of  the  galvanometer  remains  quiet.  If  either  be  warmer  than  the 
other,  the  needle  is  deflected  to  the  north  or  the  south,  according  as 
one  or  the  other  limb  has  the  higher  temperature.  By  this  apparatus, 
very  small  fractions  of  a  degree  of  temperature  can  be  determined  with 
absolute  certainty. 

Sensibility  is  not  materially,  if  at  all,  lessened,  though  the  reflex 
excitability  is  diminished,  and  often  entirely  abolished,  from  the  very 
first. 

The  faradaic  current  almost  always  fails  from  the  earliest  period 
to  cause  contractions  in  the  paralyzed  muscles,  but  the  galvanic  cur- 
rent will,  even  when  of  low  tension,  produce  movements  in  the  most 
thoroughly  paralyzed  muscles,  before  the  stage  of  atrophy  is  reached, 
but  it  will  be  observed  that  the  anodal  closure  contraction  equals, 
if  it  does  not  exceed,  the  cathodal  closure  contraction.  This  is  a 
condition  diametrically  opposite  to  a  normal  state  of  the  spinal  cord 
and  motor  nerves  (see  page  29).  As  the  atrophy  advances,  the 
muscles  respond  less  and  less  to  the  galvanic  current,  and  finally 
cease  altogether.  This  first  period  of  infantile  spinal  paralysis,  in 
which  the  loss  of  power  is  the  most  obvious  symptom,  may  last 
a  month,  or  even  six  months,  before  the  second  period,  character- 
ized by  atrophy,  begins.  It  is  then  usually  the  case  that  the  paralysis 
gradually  disappears  to  a  great  extent,  if  the  loss  of  motor  power 
has  in  the  first  place  been  extensive.  Even  when  the  paralysis  has 
been  restricted  to  a  single  limb,  some  muscles  regain  their  function, 
and  in  either  case  complete  restoration  may  occur.  In  those  parts, 
however,  in  which  there  is  no  retrogression  of  the  disease,  atrophy 
ensues,  and  advances  sometimes  with  great  rapidity.  The  tempera- 
ture falls  still  lower,  till,  in  some  cases,  it  is  scarcely  higher  than 
that  of  the  surrounding  atmosphere.  In  a  patient  from  Maine,  a 
little  girl  of  about  ten  years  of  age,  in  whom  both  the  lower  ex- 
tremities remained  paralyzed,  and  were  atrophied  to  a  very  marked 
degree,  the  temperature  of  the  legs  below  the  knee  was  only  75° 
Fahr.  in  an  atmosphere  of  72°.  The  skin  is  of  a  livid  hue,  and 
pressure  with  the  point  of  the  finger  causes  a  white  spot  to  appear, 
which  does  not  again  become  colored  for  some  time,  owing  to  the 
torpidity  of  the  capillary  circulation. 

With  this  atrophy,  the  electric  contractility  of  the  muscles  disap- 
pears, although  it  has  begun  to  be  lost  at  an  earlier  period,  and  hence 
the  strongest  induced  currents  fail  to  cause  the  slightest  contraction, 
and  in  some  cases  even  powerful  primary  currents  are  equally  ineffica- 
cious. Indeed,  in  no  other  disease  is  the  electric  excitability  so  thor- 
oughly abolished  as  in  that  under  consideration. 


INFANTILE  SPINAL  PARALYSIS.  441 

Owing  to  the  atrophy  and  consequent  weakness  of  the  muscles  which 
surround  the  articulations,  as  well  as  to  relaxation  of  the  ligaments  of 
the  paralyzed  limbs,  the  bones  entering  into  the  composition  of  the 
joints  become  separated.  This  condition  is  especially  manifested  when 
the  upper  extremity  is  the  affected  part,  as  regards  the  shoulder,  the 
head  of  the  humerus  sometimes  falling  away  from  the  glenoid  cavity  to 
the  extent  of  an  inch  or  more.  The  passive  mobility  of  the  joint  is 
therefore  very  greatly  increased,  and  dislocation  is  readily  effected. 

If,  as  is  often  the  case,  certain  muscles  of  a  limb  regain  their  power, 
while  others  remain  paralyzed,  the  normal  equilibrium  is  destroyed,  and 
distortions  of  various  kinds  are  consequently  produced.  Hence,  infan- 
tile spinal  paralysis  is  among  the  most  important  causes  of  club-feet. 

The  bones  are  also  subject  to  atrophy  and  to  arrest  of  growth,  and 
therefore  the  paralyzed  and  atrophied  limb  eventually  is  shorter  than 
the  corresponding  sound  member.  In  the  case  of  a  boy,  six  years  old, 
who,  several  years  since,  was  under  my  charge,  the  left  arm,  in  conse- 
quence of  infantile  spinal  paralysis  occurring  in  his  second  year,  was 
two  inches  shorter  than  the  right.  This  arrest  of  growth  was  not  very 
evident  when  the  child  was  dressed,  and  the  limb,  by  its  own  weight, 
hung  by  the  side,  for  the  reason  that  the  head  of  the  humerus  was  sep- 
arated nearly  two  inches  from  the  glenoid  cavity,  but,  when  the  bones 
were  brought  into  apposition,  the  shortening  was  of  course  apparent. 
This  extension  of  the  atrophy  and  arrest  of  development  to  the  os- 
seous system  is  by  no  means  an  invariable  accompaniment,  and  is  per- 
haps never  produced  unless  the  original  central  lesion  is  profound,  and 
the  muscles,  generally,  of  an  extremity  are  involved. 

Unless  death  should  occur  during  the  first  stage  of  the  disease,  it  is 
not  probable  that  spinal  infantile  paralysis  will  in  any  case  tend  to 
shorten  life.  Tho  tendency  is  for  the  spinal  lesion  to  limit  itself,  and 
hence,  when  the  second  stage  of  the  disease  appears,  there  is  no  proba- 
bility that  any  extension  of  the  morbid  process  will  take  place.  The 
consequences  are  entirely  restricted  to  the  parts  which  are  in  nervous 
relation  with  the  regior,  of  the  cord  in  which  the  central  lesion  exists. 

At  no  time  during  the  course  of  spinal  infantile  paralysis  is  either 
the  bladder  or  its  sphincter  paralyzed,  neither  is  the  sphincter  ani  de- 
prived of  its  contractile  power. 

The  muscles  most  apt,  according  to  my  experience,  to  become  the 
ultimate  seat  of  the  paralysis  and  atrophy  are  the  tibialis  anticus,  the 
peroneal,  the  deltoid,  the  gluteal,  the  extensors  of  the  toes,  and  the 
quadriceps  femoria.  I  have  never  seen  a  case  in  which  any  muscle  of 
the  head  or  neck  was  involved.  Seguin  '  states  that  the  temporal  has 
been  found  paralyzed  once.  Bed-sores  or  atrophic  ulcerations  of  the  skin 
rarely  occur.  I  have  never  observed  a  case  in  which  they  were  pr- 
— ■  fact  which  goes  to  show  that,  notwithstanding  the  appearance  of  the 
1  "  Infantile  Spinal  Paralysis,"  Medical  /iccord,  January  15, 


442  DISEASES  OF  THE  SPINAL  CORD. 

surface  over  the  paralyzed  parts,  the  nutrition  of  the  skin  is'  not  essen* 
tially  lessened. 

Causes. — Little  is  known  of  the  etiology  of  infantile  spinal  paralysis. 
In  two  cases  under  my  observation,  occurring  in  brothers,  it  was  ap- 
parently induced  by  the  nurse  allowing  the  infants  to  lie  on  the  damp 
ground  for  an  hour  or  more  ;  in  several  other  cases,  it  came  on  while 
the  children  were  suffering  from  teething,  and  in  others  it  has  followed 
diseases  of  various  kinds,  such  as  whooping-cough,  measles,  scarlet  fever, 
etc.  In  the  great  majority  of  the  cases  that  I  have  witnessed,  no  cause 
could  be  reasonably  assigned. 

More  than  half  of  the  cases  occur  during  the  first  two  years  of  life. 
M.  Duchenne  (de  Boulogne),  the  younger,1  of  fifty-six  cases  occurring 
in  the  private  practice  of  his  father,  finds  the  proportion  of  cases,  for  the 
several  ages  up  to  ten  years,  as  follows  : 

Twelve  days  after  birth 1 

At  the  age  of  one  month 1 

At  two  months 2 

At  from  four  to  six  months 6 

At  from  six  months  to  a  year 6 

From  one  year  to  eighteen  months 20 

From  eighteen  months  to  two  years 11 

From  two  to  three  years 5 

From  three  to  four  years 2 

At  seven  years , 1 

At  ten  years 1 

Total 56 

Diagnosis. — The  symptoms  of  infantile  spinal  paralysis  in  the  early 
part  of  its  first  stage  are  rarely  so  characteristic  as  to  admit  of  a  rational 
diagnosis  being  given.  They  are  such  as  are  met  with  in  many  other 
affections,  and  the  early  age  of  the  patient  is  usually  an  obstacle  to  ex- 
act inquiries.  I  shall,  under  the  head  of  morbid  anatomy,  cite  cases  in 
which  spinal  hemorrhage  has  produced  symptoms  in  some  respects  simi- 
lar to  those  of  infantile  spinal  paralysis,  but  such  cases  are  extremely  rare, 
and  they  are  not  characterized  by  the  progressive  atrophy  and  marked 
reduction  of  temperature  so  characteristic  of  the  affection  under  notice. 
Setting  them  aside,  it  is  not  probable  that,  having  in  view  the  phenomena 
of  the  disease,  the  intelligent  physician  of  the  present  day  will  blunder 
in  his  diagnosis.  The  absence  of  cerebral  symptoms,  the  cessation  of 
the  fever  when  it  has  existed,  and  the  general  good  health  of  the  pa- 
tient, will  go  to  render  the  diagnosis  still  more  certain.  The  only  con- 
dition with  which  the  disease  in  question  may  be  confounded,  is  the 
temporary  paralysis  due  to  reflex  irritations,  and  probably  the  direct 

1  Duchenne  (de  Boulogne),  "  De  l'electrisation  localisee,"  troisieme  Edition,  Parie, 
1872,  p.  417. 


INFANTILE  SPINAL  PABALYSIS.  443 

consequence  of  spinal  ancemia.  But  the  fact  that  such  irritations  are 
generally  sufficiently  evident,  and  that  the  paralysis  disappears  with 
their  removal,  will  not  permit  us  to  remain  long  in  doubt.  As  the  dis- 
ease advances  to  its  full  development,  the  symptoms  become  more  and 
more  characteristic,  until  doubt  is  scarcely  any  longer  possible.  In  fact, 
in  its  entirety,  infantile  spinal  paralysis  cannot  be  mistaken  for  any 
other  affection. 

Prognosis. — Infantile  spinal  paralysis  is  not  an  affection  liable  to 
terminate  fatally.  Death  may  possibly  occur  in  the  very  inception  of 
the  disorder  from  the  irritation  and  general  disturbance  due  to  the  in- 
flammation of  the  cord,  but,  though  I  admit  the  possibility  of  such  an 
event,  none  such  has  ever  come  under  my  observation,  nor  have  I  been 
able  to  find  any  such  recorded.  The  prognosis  is  therefore  only  of  im- 
portance as  regards  the  consequent  paralysis  and  atrophy.  And  here 
it  depends  very  much  upon  the  fact  as  to  whether  the  disease  has  ad- 
vanced so  far  as  to  have  resulted  in  the  abolition  of  the  electric  con- 
tractility of  the  affected  muscles.  If  this  is  lost  to  the  induced  current, 
the  cure  will  be  difficult,  and  the  treatment  protracted  ;  if  the  primary 
current  is  also  powerless,  a  cure  is  impossible.  I  believe  I  was  the  first 
to  use  the  primary  current  in  the  treatment  of  infantile  paralysis,  and 
to  insist  on  its  great  value  as  a  curative  agent,  and  as  an  element  in  the 
prognosis.1  If  the  muscles  can  be  made  to  contract  with  either  the  in- 
duced or  primary  currents,  the  cure  is  often  merely  a  matter  of  time 
and  patience.  But  regard  must  also  be  had  to  the  extent  of  the  pa- 
ralysis and  atrophy.  If  all  the  muscles  of  one  or  more  of  the  limbs  are 
involved,  and  if  contractions  in  the  non-affected  muscles  have  interfered 
to  any  considerable  extent  with  the  conformation  of  the  joints,  a  cure 
will  be  next  to  impossible.  While,  therefore,  recognizing  the  severity  of 
the  lesions  in  infantile  spinal  paralysis,  and  the  tediousness  of  the  meth- 
ods of  cure,  I  cannot  look  upon  the  affection  with  the  hopelessness  of 
Volkmann.5  For  with  Dr.  Radcliffe 3  I  am  every  day  more  and  more 
convinced  that  muscles  which  I  should  once  have  looked  upon  as  hope- 
lessly paralyzed,  may  be  resuscitated  by  proper  treatment. 

Again,  it  must  not  be  forgotten  that  the  most  extensive  paralysis, 
in  the  disease  under  consideration,  may  in  great  part,  or  entirel}r,  spon- 
taneously disappear  before  the  atrophy  begins  to  make  its  appearance. 
It  is  not,  therefore,  safe  to  venture  on  a  prediction  as  to  the  ultimate 
result  at  any  time  anterior  to  the  stage  of  atrophy. 

Morbid  Anatomy. — The  morbid  anatomy  of  infantile  spinal  paralysis 
is  to  be  studied  in  the  spinal  cord,  the  nerves,  the  muscles,  and  the 
bones — the  lesions  iii  the  three  latter  tissues  being  secondary  to  those 

1  New  York  Medical  Joun  '  <-r.  Is05. 

•"Ueber  Cinderl&nmong  mid  paralytUahe  Oontraotaren-SammloBg,"  Klinisdic  Vor. 
No.  1,  Leipzig,  1870. 

'  B  -vnol ■!-'-  "  Bj  iti  :n  of  Medicine,"  vol.  iii.,  p.  666. 


444  DISEASES  OF  THE  SPINAL  CORD. 

existing  in  the  cord.  Previous  to  the  recent  investigations  of  Vul- 
piac  and  Prevost,  Dr.  Lockhart  Clarke,  and  Charcot  and  his  pupils, 
there  was  no  approach  to  uniformity  relative  to  the  essential  character 
cf  the  disease,  many  observers  denying  that  there  was  any  structural 
central  lesion.  Even  since  this  last-named  distinguished  observer,  in 
conjunction  with  Joffroy,  published  the  report  of  his  notable  case,  with 
a  detailed  statement  of  the  post-mortem  appearances,  and  since  his 
results  have  been  confirmed  by  others,  we  find  so  prominent  a  teacher 
and  physician  as  Dr.  West '  ignoring  them  altogether,  and  concentrating 
his  attention  entirely  on  the  eccentric  lesions  in  a  few  brief  sentences. 
It  is  not  to  be  denied  that  paralysis  of  spinal  origin  may  exist  in 
children  and  be  a  very  different  affection  from  the  one  under  notice. 
Paralysis,  like  cough,  is  only  a  symptom  which  may  be  due  to  many 
very  different  lesions.  Thus,  in  a  case  of  paralysis  in  a  child  six  years 
of  age,  which  had  begun  four  years  previously,  and  which  involved  the 
left  lower  extremity,  I  had  the  opportunity  of  making  a  post-mortem 
examination — death  occurring  from  pneumonia.  On  examining  the 
spinal  cord,  I  found  in  the  lower  part  of  the  dorsal  region,  and  in  the 
left  anterior  column,  a  cicatrix  partially  filled  with  a  very  small  clot. 
No  microscopical  examination  was  made,  and  hence  the  condition  of 
the  anterior  cornua  was  not  ascertained.  The  atrophy  of  the  paralyzed 
muscles  was  very  slight,  and  it  is  therefore  possible  that  there  was  no 
primary  lesion  of  the  nerve-cells  of  the  anterior  horns.  The  paralysis 
had  ensued  suddenly,  and  may  have  followed  a  fall  or  a  blow — no  ac- 
curate history  could  be  obtained.  I  then,  and  for  some  time  subse- 
quently, regarded  this  case  as  one  of  infantile  spinal  paralysis  as  at 
present  understood,  but  I  am  now  entirely  satisfied  that,  beyond  the 
loss  of  motor  power,  it  had  little  in  common  with  this  affection.  The 
slight  atrophy  which  existed  was  possibly  the  result  of  secondary  de- 
generation of  a  few  cells  of  the  left  anterior  horn,  and  not  a  conse- 
quence of  any  primary  lesion  of  this  region.  A  histological  examination 
would  have  done  much  toward  the  elucidation  of  this  interesting  case, 
but  it  was  at  the  time  impossible. 

Dr.  Clifford  Allbutt3  has  reported  a  case  in  which  the  symptoms  were 
more  clearly  the  result  of  hgemorrhage.  The  patient  was  an  infant  in 
good  health,  seven  months  old.  One  evening  the  mother  lifted  the 
child  rather  suddenly,  and  was  astonished  to  see  the  body  fall  heavily 
forward.  There  were  no  evidences  of  pain,  but  she  shortly  afterward 
perceived  that  it  was  paralyzed  in  all  four  limbs.  Death  ensued  in  a 
short  time  from  implication  of  the  respiratory  nerves.  The  spinal  cord 
was  submitted  to  careful  examination,  and  two  hemorrhagic  clots  were 
discovered  in  the  cervical  region.    One  of  these,  of  small  size,  was  in  the 

1  "  On  some  Disorders  of  the  Nervous  System  in  Childhood  " — being  the  Lumleian 
Lectures  for  1871,  Philadelphia,  1871,  p.  87. 

2  The  Lancet,  vol.  ii.,  1870,  p.  84. 


INFANTILE  SPINAL  PARALYSIS.  445 

left  posterior  horn;  the  other,  larger,  was  in  the  right  posterior  horn 
and  lateral  column.  If  these  clots  had  been  formed  in  the  lower  dorsal 
region  the  infant  would  probably  have  survived,  and  the  case  might 
have  been  regarded  as  one  of  infantile  spinal  paralysis. 

In  a  case  reported  by  Hayem,1  the  patient  was  attacked  with  pa- 
ralysis of  the  lower  extremities  at  the  age  of  two  years.  Death  took 
place  twenty-two  years  afterward,  of  phthisis.  The  gray  substance  of 
the  cord  contained  blood-pigment  disseminated  through  its  substance. 

Such  instances,  as  I  have  said,  only  go  to  show  the  similarity  of  symp- 
toms which  may  result  from  very  different  causes,  and  like  examples  will 
readily  occur  to  the  reader  as  being  afforded  by  unlike  lesions  in  other 
parts  of  the  body. 

The  first  attempt  to  associate  spinal  infantile  paralysis  with  lesion 
of  the  anterior  horns  of  the  spinal  cord  was  made  by  Cornil,1  who  re- 
ported the  case  of  a  patient  affected  with  the  disease  in  question,  who 
died  of  cancer  of  the  mammary  gland  at  the  age  of  forty-nine.  The 
affection  had  been  contracted  by  the  subject,  when  an  infant  two  years 
old,  being  left  to  lie  for  a  long  time  on  cold  and  damp  ground.  The 
muscles  of  the  inferior  extremities,  especially  those  of  the  left,  were 
paralyzed  and  atrophied.  The  post-mortem  examination,  which  ex- 
tended to  the  muscles,  the  nerves,  and  the  spinal  cord,  revealed  the  ex- 
istence in  this  latter  organ  of  atrophy  of  the  anterior  horns  of  gray 
matter  and  of  the  antero-lateral  columns — in  those  parts  of  the  cord 
from  which  emanated  the  nerves  going  to  the  affected  muscles.  This 
case  was  the  first  published,  in  which  lesion  of  the  cord  was  noted  in 
connection  with  infantile  spinal  paralysis,  though  the  author  states  that 
he  had  previously,  in  1863,  observed  an  increased  development  of  con- 
nective tissue  in  the  anterior  columns.  The  case  of  hajmorrhage  coming 
under  my  own  notice,  previously  cited,  occurred  in  1858. 

Prcvost a  described,  in  18G5,  the  case  of  a  woman,  aged  seventy-eight, 
in  whom  there  was  paralysis  of  the  left  leg,  with  deformation  of  the 
foot,  evidently,  in  the  opinion  of  M.  Vulpian,  whose  patient  she  was 
in  the  Salpgtriere,  the  result  of  infantile  spinal  paralysis.  The  muscles 
of  the  left  leg  and  foot,  as  well  as  those  of  the  lower  part  of  the  thigh, 
were  much  atrophied.  The  patient  was  demented,  and  died  of  phthisis. 
Post-mortem  examination  showed  the  left  anterior  horn  of  gray  matter 
to  be  atrophied.  On  microscopical  examination,  it  was  seen  that  all 
the  external  part  of  this  horn  had  undergone  an  alteration,  the  nerve- 
cells  being  replaced  by  a  cellular  and  nuclear  tissue  evidently  the  pro 
liferation  of  the  neuroglia.  This  was  colored  red  by  carmine.  Amy- 
loid corpuscles  were  also  present.  The  ganglion-cells  of  this  part  had 
almost  entirely  disappeared,  and  the  one  or  two  that  remained  were 

"  Compter  rendus  des  s6ancc3,  et  mGmoires  de  la  80ci6t6  do  biologic,"  18C9,  1870. 
9  [bid.,  tonic  v.,  s6rie  Hi.,  1803,  p.  187. 


446  DISEASES  OF  THE  SPINAL  CORD. 

atrophied.  The  cells  of  the  internal  group  were  also  diminished  in 
number.     The  right  anterior  horn  was  normal. 

This  was  the  first  case  in  which  atrophy  and  disappearance  of  the 
cells  of  the  anterior  horn  were  found  associated  with  infantile .  spinal 
paralysis. 

In  1868,  Dr.  Lockhart  Clarke,1  in  collaboration  with  Mr.  Z.  Johnson, 
published,  under  the  head  of  muscular  atrophy,  the  details  of  a  case 
which  was  clearly  one  of  infantile  spinal  paralysis.  The  disease  had 
ensued  in  early  infancy,  immediately  after  inoculation  with  small-pox 
virus,  and  involved  both  upper  extremities,  which,  besides  being  para- 
lyzed, were  greatly  atrophied.  Examination  of  the  cord  showed  atrophy 
and  softening  of  both  anterior  horns,  with  atrophy  and  degeneration  of 
nerve-cells.     In  many  places  the  cells  had  disappeared. 

Then  in  1870,a  Charcot,  in  conjunction  with  his  pupil  Joffroy,  gave 
the  results  of  his  examination  of  a  case  which  may  be  considered  as  defi- 
nitely settling  the  question  of  the  morbid  anatomy  of  infantile  spinal 
paralysis.  The  patient,  a  woman  named  Wilson,  died  at  the  age  of 
forty-five  years,  of  phthisis,  having  been  the  subject  of  paralysis  since 
childhood.  The  disease  had  suddenly  made  its  appearance  when  she 
was  seven  years  old,  and  had  at  first  involved  all  four  limbs.  At  the 
end  of  a  year  the  upper  extremities  had  in  a  measure  regained  their 
power,  the  lower  remained  atrophied  and  nearly  altogether  paralyzed. 

On  post-mortem  examination  the  spinal  cord  was  found  to  be  affected 
from  the  cervical  to  the  lumbar  enlargement.  The  alterations  were 
chiefly  in  the  gray  matter,  and  especially  in  the  anterior  cornua.  These 
were  atrophied  and  distorted,  and  the  cells  had  disappeared  to  a  very 
great  extent.  In  some  places  entire  groups  of  cells  had  disappeared, 
without  leaving  any  traces  of  their  former  presence.  In  the  immediate 
vicinity  of  some  of  the  points  of  cellular  atrophy,  the  neuroglia  had  un- 
dergone sclerous  transformation,  but  there  were  places  where  the  lesion 
of  the  cells  was  the  only  alteration  which  could  be  discovered. 

Since  the  publication  of  the  details  of  Charcot's  case,  several  others 
have  been  reported,  and  a  number  of  excellent  monographs  have  been 
written  in  illustration  of  the  morbid  anatomy  of  infantile  spinal  paraly- 
sis. Among  these  may  be  cited  those  of  Parrot  and  Joffroy,3  Roger  and 
Damaschino,4  Dujardin-Beaumetz,5  Petitfils,8  Seguin,7  Putnam- Jacobi,8 

1  "  On  a  Remarkable  Case  of  Extreme  Muscular  Atrophy,  with  Extensive  Disease  of 
the  Spinal  Cord,"  "  Medieo-Chirurgical  Transactions,"  Second  Series,  vol.  xxxiii.,  1868, 
p.  249. 

2  "  Archives  dc  Physiologic,"  tome  iii.,  1870,  p.  135. 

3  Ibid.,  1870,  p.  310. 

*  "  Rechorchcs  anatomo-pathologiques  sur  la  paralysie  de  l'enfance,"  Gazette  Midu-ale. 
<U  Paris,  1871,  Nos.  41,  43,  45,  48,  and  51.  E  "  De  la  myelite  aigue,"  Paris,  1872. 

e  "Considerations  sur  l'atrophie  des  cellules  motrices,"  Paris,  1873. 
1  "Infantile  Spinal  Paralysis,"  Medical  Record,  January  15,  1874. 

*  American  Journal  of  Obstetrics,  May,  1874. 


INFANTILE  SPINAL  PARALYSIS. 
Fig.  34. 


447 


and  Charcot,1  who  has  quite  recently  traversed  the  whole  ground,  and 
who  has  admirably  summed  up  what  is  known  of  the  whole  subject. 


Fig.  33. 


1  Rune  photographiqut  dm  hdpitavx,  Janvier  ct  F6vrier,  1872,  and  "Le9ons  sur  loo 
naladlea  du  systeme  nerveux,"  fascicule  iii.,  Paris,  1874. 


448 


DISEASES   OF   THE   SPINAL   CORD. 


They  all  go  to  show  that  the  essential  lesion  in  infantile  spinal  paraly- 
sis is  situated  in  the  anterior  horns  of  gray  matter,  and  that  it  consists 
of  a  myelitis,  in  consequence  of  which  there  is  an  atrophy  of  the  part 
affected,  a  degeneration  of  its  structure,  and  a  disappearance  of  its  cell- 
elements.  This  contraction  or  atrophy  is  well  shown  in  the  accompa- 
nying woodcut  from  Charcot  (Fig.  34),  which  represents  a  magnified 
section  of  the  spinal  cord  taken  from  the  cervical  region  of  a  woman, 
aged  fifty  years,  who  died  in  the  Salpetriere,  of  general  paralysis  of  the 
insane,  and  in  whom  there  was  infantile  spinal  paralysis  affecting  the 
right  superior  extremity.  The  atrophy  of  the  right  anterior  horn  is 
well  marked,  and  the  emaciation  of  the  right  antero-lateral  and  poste- 
rior columns,  probably  a  secondary  complication,  is  also  notable. 

The  atrophy  and  disappearance  of  the  nerve-cells  are  sometimes  ex- 
ceedingly limited.  In  the  accompanying  figure  (Fig.  35),  also  from  Char- 
cot, an  enlarged  view  is  given  of  a  section  of  the  spinal  cord  taken  from 
the  lumbar  region  in  a  case  of  infantile  spinal  paralysis,  affecting  the 
right  lower  extremity  :  A,  the  left  anterior  horn,  healthy  ;  a,  healthy 
group  of  ganglion-cells  ;  J3,  right  anterior  horn  ;  b,  median  ganglionary 
nucleus,  of  which  the  cells  are  destroyed,  and  which  is  represented  by  a 
foyer  of  sclerosis.    In  Fig.  36  a  still  more  enlarged  view  is  given  of  the 

Fig.  36. 


right  anterior  horn  :  er,  cervix  of  the  posterior  horn  ;  b,  postero-external 
group  of  nerve-cells  ;  c,  antero-external  group,  the  cells  of  which  have 
entirely  disappeared,  while  they  are  intact  in  groups  b  and  d ;  d,  inter- 
nal group  ;  c,  the  commissure. 

The  myelitis  is  parenchymatous  in  character,  that  is,  it  begins  in  the 


INFANTILE  SPINAL  PARALYSIS.  449 

nerve-cell  structure,  and,  if  the  neuroglia  be  found  involved,  it  is  from 
the  extension  of  the  morbid  process,  and  not  from  any  primary  implica- 
tion. This  is  sufficiently  established,  not  only  from  an  examination  of 
sections  of  the  cord,  such  as  that  represented  in  the  last  figure  in  which 
the  lesion  is  restricted  to  the  nervous  elements,  but  from  a  consideration 
of  the  physiological  relation  which  exists  between  the  cells  of  the 
anterior  horn  and  the  functions  which  they  have  to  perform — func- 
tions which  are  interfered  with  in  cases  of  infantile  spinal  paralysis. 

Roger  and  Damaschino '  have  had  the  opportunity  of  making  histo- 
logical examinations  in  three  cases  of  infantile  spinal  paralysis,  in  which 
death  took  place  from  intercurrent  affections  while  the  disease  was  still 
in  its  early  stage.  As  the  result  of  their  observations  they  concludo 
that — 

"  1.  The  characteristic  alteration  of  infantile  paralysis  is  a  lesion 
of  the  spinal  cord,  of  which  the  atrophy  of  the  nerves  and  muscles  is 
the  consequence. 

"2.  This  lesion  is  more  particularly  seated  in  the  anterior  portion 
of  the  gray  spinal  substance,  where  it  is  seen  in  the  form  of  centres  of 
softening. 

"  3.  This  softening  is  of  an  inflammatory  character,  and  the  disease 
is  a  myelitis. 

"4.  Infantile  paralysis  ought  therefore  to  be  called  infantile  spinal 
paralysis,  and  moreover  its  nosological  position  is  certainly  among  the 
affections  of  the  cord,  and  among  the  myelites." 

As  regards  the  cell-alterations  they  found  them  to  consist  in  atro- 
phy, with  pigmentation. 

Charcot3  has  figured  the  changes  which  the  cells  of  the  anterior 
horns  undergo  in  such  cases  :  A  represents  the  normal  state  ;  JB,  a  cell 
hypertrophied  ;  (7,  pigmentary  alteration  of  the  last  stage  of  pigmen- 
tary change  ;  E,  a  cell  in  a  state  of  sclerous  atrophy  ;  and  F,  vacuolary 
alteration,  which  latter  may  be  the  result  of  the  processes  used  in  pre- 
paring the  specimens — Fig.  37. 

The  anterior  roots  of  the  nerves  coming  from  the  afTected  region 
have  been  found  atrophied,  the  rnycline  having  disappeared,  and  only 
the  axis-cylinder  remaining.  In  other  cases  the  nerve-tubules  have  been 
found  to  be  very  attenuated,  and  separated  from  each  other  by  large 
spaces  filled  with  connective  tissue. 

The  ganglia  of  the  sympathetic  have  been  examined  by  Roger  and 
Damaschino,  but  exhibited  no  change  from  their  normal  structure. 

The  bones  of  the  paralyzed  parts  undergo  atrophy  with  the  mi 
though,  whi  11  the  Lesion  is  not  extensive,  the  bony  atrophy  may  escape 
recognition.     Wo  have  already  seen  that  the  affected  extremities  are 
often  submitted  to  an  arrest  or  retardation  of  growth.    Besides  this  con- 

1  Op.  tit. 

*  Lecons  sur  les  maladies  du  syst6me  ncrvcux,  troisidmc  partie,  1'aiis,  1871,  p.  184. 
30 


450  DISEASES  OF  THE  SPINAL   CORD. 

dition,  there  is  a  cessation  in  the  development  of  the  bone  laterally,  and 
consequently  its  shaft  remains  smaller  than  is  natural.  The  articular  ex- 
tremities of  the  affected  bones  lose  their  cartilages,  and  are  more  or 

Fig.  37. 


less  arrested  in  their  development.  Examined  microscopically,  as  has 
been  done  by  Laborde  '  and  others,  the  osseous  tissue  is  found  to  present 
a  deficient  number  of  bone-cells  and  an  excessive  amount  of  medullary 
elements  and  adipose  matter.  It  does  not  appear  that  the  normal  rela- 
tion of  earthy  to  animal  matter  is  disturbed  to  such  an  extent  as  to 
render  the  bones  either  especially  liable  to  fracture  or  distortion. 

But,  of  all  the  peripheric  lesions,  those  of  the  muscles  have  attracted 
the  most  attention,  and  have  been  the  most  carefully  studied.  It  ap- 
pears to  be  settled  without  doubt  that  the  first  stage  of  atrophy  is  char- 
acterized by  a  diminution  of  the  diameter  of  the  muscular  fibrilla?,  and 
that  there  is  not  then  any  histological  evidence  of  a  tendency  to  fatty 
degeneration. 

At  this  time  there  is  an  increased  formation  of  connective  tissue — 
a  process  which  appears  to  persist  for  a  considerable  period. 

Eventually  the  atrophied  muscles  tend,  in  the  great  majority  of 
cases,  to  break  down  into  fat.  The  transverse  striae  disappear,  and  the 
degeneration,  at  first  granular  and  bony,  becomes  unmistakably  fatty. 
Eventually  the  muscle  consists  of  nothing  but  fat  and  connective  tissue, 
and  in  time  the  former  disappears,  leaving  only  a  mass  composed  of  the 
sarcolemmae  and  connective  tissue. 

The  nature  of  the  morbid  process  is  well  shown  in  the  accompanying 
woodcuts,  made  from  my  own  drawings  of  the  microscopical  appear- 

1 "  Dc  la  paralysie  essentielle  de  1'enfance,"  These  de  Paris,  1864,  p.  30. 


INFANTILE  SPINAL  PARALYSIS. 


451 


ances  of  portions  of  diseased  muscles  removed  by  Duchenne's  trocar. 
Fig.  38  represents  a  portion  of  the  upper  part  of  the  tibialis  anticus 
muscle  of  a  boy  who  had  suffered  from  organic  infantile  paralysis  for 
over  two  years,  and  in  whom  the  progress  of  the  atrophy  was  exceed- 


Fio.  38. 


ingly  rapid.  Oil-globules  are  seen  along  the  course  of  the  fibrillae. 
These  latter  are  irregular  and  torn,  and  the  transverse  strias  are  becom- 
ing dim. 

In  Fig.  39  a  still  more  advanced  stage  is  shown.     This  cut  repre- 


Fia.  39. 


^ 


sents  a  portion  of  the  same  muscle  taken  from  the  lower  part.  The 
transverse  strire  have  nearly  disappeared,  oil-globules  arc  seen  in  large 
numbers,  and  fat-corpuscles  are  also  abundant. 

In  Fig.  40  the  progress  of  the  disease  is  well  shown.     The  upper 


Fio.  40. 


margin  of  the  specimen  is  a  mass  of  fat-globules,  and  throughout    the 
whole  the  transverse  stria)  arc  absent. 

In  Fig.  41  is  shown  a  portion  taken  from  the  same  muscle  one  month 
after  the  preceding  specimens  were  removed.  The  transverse  stria)  aro 
entirely  gone,  and  the  muscle  is  a  mass  of  oil-globules  and  fat-vesi- 
cles. 


452 


DISEASES  OF  THE   SPINAL   CORD. 
Fig.  41. 


Fig.  42  represents  a  piece  of  the  same  muscle  six  weeks  later.  It 
is  now  nothing  more  than  a  mass  of  connective  tissue,  the  fat  being 
almost  entirely  absorbed  ;  no  transverse  or  longitudinal  stria?  are  to  be 
perceived. 


Fio.  42. 


Cb 


But  there  is  not,  as  Duchenne  affirms,  this  degeneration  in  every 
case  of  organic  infantile  paralysis.  In  two  cases,  which  had  lasted  over 
four  years,  I  found  the  structure  of  the  muscle  unchanged.  There  were 
atrophy,  loss  of  electric  contractility,  and  reduction  of  temperature,  but 
every  specimen  of  the  affected  muscles  that  I  examined  showed  no 
change  from  the  normal  character.  In  every  other  respect  the  symp- 
toms were  similar  to  those  observed  in  ordinary  cases  of  the  disease. 
Improvement  was  very  slow,  but  finally  every  muscle  except  the  rectus 
femoris  in  one,  and  the  tibialis  anticus  in  the  other,  recovered,  and  the 
children  were  enabled  to  walk.  The  affection  in  both  cases  was  con- 
fined to  the  left  lower  extremity. 

I  am  hence  led  to  the  conclusion  that  fatty  degeneration  of  muscles, 
though  the  ordinary  result  of  organic  infantile  paralysis,  is  not  an  inva- 
riable consequence.1 

Pathology. — Whether  all  the  cells  of  the  anterior  horns  of  gray 
matter  are  motor,  or  whether  there  are  both  motor  and  trophic  cells, 
are  questions  which  the  histological  examination  of  the  normal  struct- 

1  Journal  of  Psychological  Medicine,  No.  1,  18G7,  p.  &tI.  Since  the  observations  then 
published,  other  observers  have  arrived  at  the  same  conclusion.  Thus,  M.  Charcot  (Op. 
cil.,  p.  lfil)  says:  "The  surcharge  of  fat,  although  habitual  in  old  cases  of  infantile  mus- 
cular atrophy,  is  nevertheless  not  necessary.  By  the  side  of  the  muscles  distended  with 
fat,  there  are  often  others  which  arc  reduced  to  a  very  small  volume,  and  in  which  the 
adipose  tissue  is  almost  entirely  absent.  In  these  last  are  found  primitive  fasciculi  of 
very  small  diameter,  but  possessing  their  characteristic  striation." 


INFANTILE  SPINAL  PARALYSIS.  453 

ure  seems  to  be  quite  incapable  of  satisfactorily  answering.  Samuel ' 
has  contended  for  the  existence  of  a  distinct  system  of  nerves,  the 
function  of  which  is  to  preside  over  the  nutrition  of  the  parts  to  which 
they  are  distributed,  and  there  is  not  wanting  physiological  evidence  to 
support  his  theory  ;  as,  for  instance,  the  troubles  of  nutrition  which 
result  in  the  eye  when  the  fifth  pair  is  divided,  and  "which  Yulpian " 
admits  are  due  neither  to  irritation  of  the  divided  nerve-fibres  nor  to 
paralysis  of  the  vaso-motor  fibres  contained  in  the  nerve.  Waller  3  has 
also  expressed  his  opinion  relative  to  the  existence  of  distinct  trophic 
centres  in  the  cord.  He  regarded  the  ganglion  of  the  posterior  root  as 
the  trophic  centre  for  this  root,  while  che  gray  substance  of  the  an- 
terior horns  is  the  trophic  centre  for  the  anterior  root.  In  regard  to 
this  theory,  Weir  Mitchell4  expresses  the  opinion  that  it  is  still  a  matter 
of  doubt,  in  which  view  all  will  unite  till  actual  demonstration  settles  it 
affirmatively  or  negatively. 

But  pathology  points  still  more  clearly  than  does  physiology  to  the 
existence  of  trophic  cells  in  the  spinal  cord.  In  infantile  spinal  pa- 
ralysis the  peripheric  disturbance  is,  in  the  first  place,  solely  one  of 
motility  ;  there  is  paralysis  without  atrophy.  After  a  time,  which 
may  be  as  much  as  six  months,  or  even  more,  the  trophic  changes  be- 
gin. These,  as  we  have  seen,  are  not  of  that  mild  character  resulting 
from  disuse,  but  are  active  and  intense,  leading  to  the  certain  destruc- 
tion of  whole  groups  of  muscles,  and  even  to  arrest  of  development  and 
degeneration  of  the  bones.  It  is  impossible,  it  appears  to  me,  to  ac- 
count satisfactorily  for  this  atrophic  process  on  the  supposition  that  all 
the  cells  of  the  anterior  horns  of  gray  matter  are  motor,  and  that  they 
alone  are  involved  in  the  lesion.  Charcot,  however,  constantly  speaks 
of  the  affection  in  question  as  essentially  consisting  in  an  atrophy  and 
disappearance  of  motor  nerve-cells,  and  the  majority  of  French  writers 
adopt  his  view.  Indeed,  he  argues  very  strenuously  against  the  exist- 
ence of  spinal  trophic  cells,  in  which,  it  appears  to  me,  he  ignores  some 
of  the  most  valuable  contributions  which  he  and  others  of  his  country- 
men have  made  to  the  pathology  of  the  nervous  system.  A  very  impor- 
tant memoir  of  MM.  Duclienne  and  Joffroy  *  throws  much  light  upon  this 
interesting  subject,  and  will  be  fully  considered  under  the  head  of  pro- 
gressive muscular  atrophy,  when  additional  evidence  in  support  of  the 
theory  of  the  existence  of  trophic  cells  will  be  adduced. 

But,  whether  we  admit  the  existence  of  trophic  cells  in  the  anterior 
horns  of  gray  matter  or  not,  there  is  no  doubt  of  the  dependence  of  the 

1  "  Die  tropischen  Nerven,"  Leipzig;  1860. 

9  "  Lccons  sur  l'appareil  raso-moteur,"  Paris,  1875,  tome  ii.,  p.  .177. 
'  "  Proceedings  of  the  Royal  Society  of  London,"  vol.  ii.,  1860-'62. 
4  ".Injuries  of  Nerves  and  their  Consequences,"  Philadelphia,  1872,  p. 
«"I»r  ['atrophic  aigni  let  ohronique  des  cellules  nen  >.,  Archives  de  pUgti 

olitgie,  No.  1,  1870,  p.  199. 


454  DISEASES  OF  THE  SPINAL  CORD. 

peripheric  troubles  on  the  central  lesion.  Some  authors  have  assumed 
that  the  essential  feature  of  the  disease  was  some  disturbance  in  the 
sympathetic  nervous  system;  but  there  is  no  evidence  to  support  this 
view.  On  the  contrary,  examination  has  shown  that  there  is  no  appre- 
ciable lesion  of  this  system,  and  the  fact  that  all  the  functions  of  the 
organism  are  generally  well  performed  in  cases  of  infantile  spinal  pa- 
ralysis militates  strongly  against  the  hypothesis. 

No  examination  of  the  cord  of  a  patient  dying  during  the  very  ear- 
liest stage  of  infantile  spinal  paralysis  has  yet  been  made.  Judging, 
however,  from  the  character  of  the  symptoms,  and  from  their  diffusion, 
and  subsequent  retrogression,  it  is  extremely  probable  that,  as  in  other 
inflammatory  affections,  there  is  congestion,  and  that  this  condition  is 
not  limited  to  the  anterior  tract  of  gray  matter.  As  we  have  seen, 
pains  not  only  in  the  cord,  but  in  the  limbs,  are  occasionally  met  with, 
and  Vulpian '  refers  to  an  instance  in  which  there  was  complete  anaes- 
thesia. In  the  case  of  a  little  girl  whom  he  examined  a  few  days  after 
the  invasion  of  the  disease,  and  in  whom  the  electro-muscular  contrac- 
tility of  the  muscles  of  both  inferior  extremities  was  entirely  abol- 
ished to  strong  faradaic  currents,  sensibility  was  equally  annihilated, 
so  that  the  electric  brush  could  be  passed  over  the  skin  without  pain 
being  produced. 

The  pathology  of  the  deformations  so  generally  met  with  in  cases 
of  infantile  spinal  paralysis  is  very  obviously  the  result  of  the  destruc- 
tion or  impairment  of  that  normal  equilibrium  which  exists  between  the 
muscles.  Thus,  if  the  extensors  of  the  hand  are  affected  while  the 
flexors  remain  unparalyzed,  these  latter  will  in  time  cause  a  flexion  of 
the  hand  upon  the  forearm  ;  if  the  muscles  of  one  side  only  of  the  spine 
are  paralyzed,  the  muscles  of  the  other  side  will  produce  a  lateral  curva- 
ture; if  the  extensors  of  the  foot  are  alone  deprived  of  their  power,  the 
strong  gastrocnemius  and  soleus  cause  a  talipes  equinus;  while,  if  these 
latter  are  the  seat  of  the  derangement  while  the  extensors  are  healthy, 
a  talipes  calcaneus  is  the  result  ;  and  these  conditions  are  more  or  less 
modified  according  as  other  muscles  are  more  or  less  involved. 

Treatment. — The  fact  that  infantile  spinal  paralysis  is  due  to  an 
organic  affection  of  the  spinal  cord  is  no  bar  to  treatment  addressed  to 
the  peripheric  lesions — it  having  been  very  definitely  shown  by  numer- 
ous investigations  that  the  integrity  of  nerve-centres  is  affected  either 
favorably  or  unfavorably  by  eccentric  nerve-conditions.  It  is  therefore 
perfectly  practicable,  in  favorable  cases  of  the  disease  in  question,  so  to 
improve  the  nutrition  of  the  cord,  by  proper  measures  directed  to  the 
relief  of  the  peripheric  trouble,  as  to  arrest  the  morbid  process  in  the 
cells  of  the  anterior  horns,  and  even  to  effect  their  regeneration.  The 
fact  that  cases  of  long-standing  infantile  spinal  paralysis  are  cured — 
cases  in  which  there  can  be  no  doubt  of  the  existence  of  the  spinal 
1  "  Lemons  sur  l'appareil  vaso-motcur,"  Paris,  1875,  tome  ii.,  p.  410. 


INFANTILE  SPINAL  PARALYSIS.  455 

lesion — is  of  itself  sufficient  evidence  to  establish  the  correctness  of  the 
view  advanced.  The  investigations  of  MM.  Masius  and  Van  Lair,1 
relative  to  the  regeneration  of  the  spinal  cord,  also  show  how  great  is 
the  reparative  power  of  the  organ.  They  divided  the  cord  in  frogs, 
and  at  the  end  of  from  two  to  four  months  obtained  indubitable  evi- 
dence that  the  animals  had  regained  voluntary  movements  and  sensi- 
bility in  the  posterior  extremities.  In  other  frogs,  histological  exami- 
nation showed  the  more  or  less  complete  regeneration  of  the  cord. 
The  conditions  which  lead  us  to  expect  a  favorable  or  an  unfavorable 
result  from  treatment  are  stated  under  the  head  of  prognosis. 

The  treatment  of  the  disease,  however,  consists  both  in  the  use  of 
general  and  local  means.  Of  the  former,  ergot  is  chief,  and  should  be 
given  as  soon  as  we  can  determine  the  nature  of  the  disease  under 
which  the  child  is  suffering.  Young  children  bear  this  remedy  well. 
Infants  of  six  months  may  take  as  much  as  ten  drops  of  the  fluid-ex- 
tract three  times  a  day,  and  this  may  be  increased  to  half  a  drachm  for 
children  of  from  one  to  two  years.  It  is  rarely  the  case,  however, 
that  we  have  the  opportunity  of  giving  this  valuable  agent  from  the 
very  inception  of  the  disease.  But  even  after  the  first  or  febrile  stage 
has  subsided,  when  the  affection  is  solely  manifested  by  paralysis,  be- 
fore the  atrophic  stage  has  begun,  ergot  is  of  great  service — not  to  bo 
surpassed,  in  my  opinion,  by  any  other  medicine,  and  the  only  one 
capable  of  cutting  short  the  disease,  or  lessening  its  extent. 

After  the  stage  of  atrophy  is  reached  there  is  no  longer  any  benefit 
to  be  derived  from  ergot  ;  strychnia  is  then  useful  because  it  is  ca- 
pable of  acting  as  a  general  stimulant  to  the  nervous  system,  is  pos- 
sessed of  undoubted  value  in  cases  of  degeneration  of  nervous  tissue, 
and  is,  moreover,  a  tonic  to  the  muscles.  I  generally  prescribe  it  in 
union  with  iron  and  phosphoric  acid,  according  to  the  following  form- 
ula: $.  Strychnia;  sul.  gr.  j,  ferri  pyrophosph.  3  ss.,  acidi  phosphorici 
|  ss.,  syrupus  zingiberis  3  iijss.  M.  ft.  mist.  Dose,  a  teaspoonful  or 
less,  according  to  the  age  of  the  patient.  A  child  of  from  three  to 
five  years  of  age  can  take  half  a  teaspoonful  of  this  mixture  thrice 
daily;  or,  the  strychnia  may  be  given  advantageously  in  the  form 
of  hypodermic  injections  in  doses  suitable  to  the  age.  In  children 
under  one  year  old,  the  ninety-sixth  of  a  grain  is  as  much  as  should 
be  given  at  a  dose,  and  under  six  months  it  should  not  be  administered 
at  all.  I  am  quite  sure  that  strychnia,  hvpodermically  introduced  in 
very  gradually-increased  doses,  is  more  efficacious  than  when  taken 
into  the  stomach. 

The  immediately  local  means  of  treatment  are  those  which  are  cal- 
culated to  promote  f  he  nutrition  of  the  muscles,  and  restore  or  augment 
their  contractile  power.     The  first  end  is  effected  by  causing  a  greater 

1  "  Recheichcs  experimcntalcs  sur  la  r6g6n6ration  anatoin'wiue  ct  functionnellc  do  i» 
moclle  opinion:,"  analyzed  in  Archives  de  I'hysiologie,  tonic  iv.,  p.  268. 


45G  DISEASES  OF  THE  SPINAL  CORD. 

amount  of  blood  to  flow  through  the  diseased  parts;  the  second  is  best 
accomplished  by  the  persistent  use  of  electricity,  and  active  and  passive 
exercise. 

Under  the  first  head  are  embraced  heat,  friction,  and  kneading. 

Heat  is  best  applied  by  means  of  hot  water.  A  temperature  of 
from  110°  to  120°  Fahr.  may  be  used,  and  the  limb  should  be  thor- 
oughly immersed,  and  allowed  to  remain  so  for  half  an  hour ;  salt 
may  be  added  to  the  water,  with  the  view  of  augmenting  the  stimulant 
effect. 

Frictions  with  a  dry  towel,  a  flesh-brush,  or  the  hand,  are  also  ex- 
ceedingly useful;  they  should  be  practised  several  times  in  the  course 
of  the  day,  to  the  extent  of  reddening  the  skin. 

Kneading  the  muscles  affords  a  means  of  exercising  them,  and  of  in- 
creasing the  amount  of  blood  in  the  vessels.  They  should  be  pinched 
firmly  between  the  fingers  of  both  hands  to  the  extent  of  producing 
some  little  pain;  every  paralyzed  muscle  should  be  gone  over  in  this 
way  daily. 

Jounod's  boot,  when  the  inferior  extremity  is  the  one  affected,  or  a 
similar  apparatus  for  the  upper  extremity,  is  an  efficacious  means  of 
causing  an  increased  flow  of  blood  to  the  parts,  and  of  producing  a  per- 
manent enlargement  of  the  vessels.  Care,  however,  should  be  taken 
that  the  exhaustion  of  the  air  be  not  carried  too  far. 

Under  the  second  head,  electricity  comes  first.  If  the  induced  cur- 
rent will  produce  contractions  in  the  affected  muscles,  it  should  be  em- 
ployed; but  if,  as  often  happens,  it  should  fail  to  do  so,  the  primary 
current  interrupted  must  be  brought  into  service.  In  the  communica- 
tion '  already  cited,  I  called  attention  to  this  valuable  agent  in  the 
treatment  of  oiganic  infantile  paralysis,  and  adduced  several  cases  in 
illustration  of  its  beneficial  action.  If  a  contraction  can  be  induced  by 
it,  recovery  is  merely  a  matter  of  time,  so  far  as  that  particular  muscle 
is  concerned.  As  soon  as  the  muscle  is  so  far  developed  as  to  contract 
to  the  induced  current,  this  latter  should  be  employed.  Every  alter- 
nate day  is  Often  enough  for  a  sitting.  The  time  necessary  for  each  is, 
of  course,  dependent  on  the  extent  of  the  paralysis. 

During  the  period  from  December,  18G5,  to  December,  1870,  I 
treated  ninety-eight  cases  of  organic  infantile  paralysis.  Of  these,  the 
disease  was  so  far  advanced  in  eleven  as  to  render  it  very  evident,  after 
thorough  examination,  that  success  was  out  of  the  question.  In  the 
remaining  eighty-seven,  no  contractions  could  be  caused  in  the  affected 
muscles  by  the  strongest  induced  currents  in  thirty-nine;  while  in  all 
of  these  the  primary  current  produced  decided  contractions.  Of  the 
eighty-seven  cases,  fourteen  were  entirely  cured;  twenty-eight  were 
greatly  improved;  thirty  slightly  improved,  and  the  remainder — fifteen 
— discontinued  treatment  before  sufficient  time  had  elapsed  to  ascertain 
1  New  York  Medical  Journal^  December,  1865. 


INFANTILE  SPINAL  PARALYSIS. 


437 


the  effect.  Since  then  I  have  kept  no  very  full  record  of  my  cases,  but 
I  am  enabled  to  state  that  the  proportions  do  not  vary  essentially  from 
those  above  stated. 

At  the  best,  however,  the  treatment  must  be  of  long  duration,  and 
even  when  the  muscles  arc  entirely  restored  they  must  be  reeducated 
to  the  performance  of  their  functions.  Few  parents,  comparatively, 
have  the  patience  to  wait  and  to  devote  the  necessary  time  to  doing 
their  part  of  the  work;  unless  there  is  a  reasonable  assurance  in  regard 
to  these  points,  it  is  better  not  to  undertake  the  case.  It  is  not,  except 
in  recent  cases,  a  matter  of  days,  or  of  weeks,  but  of  months,  and  some- 
times of  years. 

But,  even  when  fatty  degeneration  is  going  on,  the  disease  may  be 
arrested  by  the  proper  use  of  the  direct  current.  Fig.  43  shows  the  ap- 
pearance of  a  portion  of  muscle  as  examined  by  the  microscope,  October 

Fig.  43. 


21,  1SC6.  This  specimen  was  removed  from  the  belly  of  the  gastro- 
cnemius muscle  before  any  treatment  whatever  had  been  employed,  and 
after  the  disease  had  existed,  with  gradually-advancing  atrophy,  for 
about  four  and  a  half  months. 

Fig.  44  represents  a  piece  of  the  same  muscle  from  the  same  part, 
on  December  3d,  six  weeks  after  the  treatment  was  begun.  In  the 
first,  oil-globules  are  seen  to  have  displaced  the  muscular  tissue  to  a 

Fio.  44. 


great  extent;  the  transverse  strin-  have  disappeared  entirely  from  some 
parts,  and  are  faintly  seen  even  where  they  are  present.  In  the  second, 
the  quantity  of  fa1  is  perceived  to  be  very  much  lessened,  and  the  strke 
are  much  more  numerous  and  distinct.  This  case,  which  was  one  of  pa- 
ralysis of  the  li'l'i  leg  and  foot,  entirely  recovered. 

I  feel  that  1  cannol  insist  too  strongly  on  the  use  <>f  the  primary  or 
galvanic  current,  when  contractions  cannot  he  obtained  by  the  faradaio 


458  DISEASES  OF  THE  SPINAL   CORD. 

or  induced  current.  If  the  electric  contractility  of  the  muscles  is  not 
utterly  destroyed — as  Dr.  Radcliffe '  remarks — there  appears  to  be  no 
limit  to  the  prospect  of  recovery. 

Whichever  form  of  current  be  employed,  it  must  be  applied  directly 
to  the  skin  over  the  affected  muscles,  or,  in  some  cases,  to  the  nerves 
which  go  to  them;  and  the  current  should  be  as  strong  as  is  necessary 
to  cause  contractions.  Applying  it  through  the  hand  of  the  physician 
is  worse  than  useless. 

Along  with  the  electricity,  passive  motions  of  the  joints  should  be 
made,  and  the  child  should  be  encouraged  to  direct  the  will  to  the 
affected  muscles  as  often  and  as  powerfully  as  possible. 

A  very  valuable  aid  to  the  treatment,  in  cases  of  deformities,  is  af- 
forded by  the  use  of  apparatus  calculated  to  take  the  tension  from  the 
paralyzed  muscles.  An  overstretched  muscle  is  in  the  worst  possible 
state  to  react  to  the  electrical  stimulus,  for  the  strain  is  of  itself  a  most 
efficient  agent  in  destroying  its  contractility.  India-rubber  cords  may 
be  very  advantageously  employed  in  this  connection. 

As  to  tenotomy,  the  question  of  its  propriety  must  be  determined 
by  the  circumstances  of  each  individual  case,  and  may  be  left  to  the 
good  sense  of  a  competent  orthopaedic  surgeon. 

b.  Spinal  Paralysis  of  Adults. 

Duchenne,"  to  whom  we  owe  the  identification  of  several  other 
affections  of  the  nervous  system,  was  the  first  to  insist  upon  the  fact 
that  there  was  a  form  of  paralysis  met  with  in  adults  which  presented 
great  analogies  with  infantile  spinal  paralysis.  He  recognized  two 
forms  of  this  disorder,  one  he  designated  acute  anterior  spinal  fjaralysis 
of  adults,  the  other  subacute  general  anterior  spinal  paralysis  of 
adults.  As  these  have  the  same  patho-anatomical  features  and  differ 
in  their  symptoms  only  as  regards  a  few  not  very  material  points,  there 
is  nothing  to  be  gained  by  considering  them  separately. 

In  the  third  and  last  edition  of  his  great  work,3  under  the  head  of 
spinal  p>aralysis  in  the  adult,  he  sums  up  his  earlier  and  more  recent 
investigations  on  the  subject. 

But,  though  Duchenne  has  shown  by  the  cases  recorded  in  the  first 
edition  of  his  work  published  in  1855,  and  the  remarks  therein  made 
in  regard  to  them,  that  he  was  acquainted  with  a  form  of  spinal  paral- 
ysis occurring  in   adults   characterized   by  loss   of    voluntary  power, 

•  Article  "  Infantile  Paralysis."     Reynolds's  "  System  of  Medicine,"  vol.  ii. 

•  As  these  pages  are  passing  through  the  press,  the  death  of  this  distinguished  phy- 
sician  is  announced.  Probably  no  one  man  has  done  so  much  as  he  for  the  advancement 
of  neuro-pathology  and  therapeutics.  The  keenness  of  his  observation  was  only  equaled 
by  his  indomitable  spirit  of  investigation  and  immense  capacity  for  work.  In  him  scien- 
tific medicine  has  lost  a  follower  whose  place  will  not  soon  be  filled. 

•  "De  l'electrisation  localised,"  Paris,  1872,  p.  437. 


SPINAL  PARALYSIS  OF  ADULTS.  459 

atrophy,  and  diminished  electric  contractility  in  the  muscles,  "  as  "when 
the  anterior  columns  of  the  cord  are  altered,"  Meyer,1  of  Berlin,  is 
entitled  to  the  credit  of  being  the  first  clearly  to  state  in  a  publication 
his  belief  in  the  existence  of  an  affection  holding  intimate  relations  with 
infantile  paralysis  and  to  employ  the  term  spinal  paralysis  of  adults. 
Thus,  after  describing  the  first  named  disease  he  says  : 

"A  similar  paralysis  of  the  lower  extremities  occurs  also  in  adults, 
occasioned  by  the  existence  of  some  exanthematous  action  or  other 
unknown  cause.  The  disease  in  such  cases  is  of  course  subject  to  such 
modifications  as  the  completed  structure  of  the  body  would  induce. 
Among  these  are  the  following  :  1.  As  the  bones  of  the  adult  are  fully 
developed,  that  retardation  in  the  structural  growth  of  the  affected 
members,  which  may  occur  in  cases  of  infantile  spinal  parahysis,  has 
here  of  course  no  place.  2.  In  consequence  of  the  adult's  greater  energy 
of  w?ill  impelling  him  to  bring  into  action  muscles  which  can  be  made  to 
perform  the  duties  of  the  paralyzed  ones,  as  well  as  in  consequence  of 
the  greater  firmness  and  resisting  power  of  the  ligaments  of  the  adult, 
secondary  deformities  are  not  developed  to  the  same  extent  as  in  the 
spinal  paralysis  of  children.  3.  As  in  no  case,  so  far  as  my  observation 
goes,  is  the  power  of  locomotion  removed,  there  cannot  be  so  great  a 
disturbance  in  the  circulation  of  the  blood,  nor,  consequently,  so 
remarkable  a  reduction  of  temperature.  4.  On  the  other  hand,  as  a 
result  of  the  double  amount  of  work  devolved  upon  the  muscles  that 
perform  the  duties  of  the  paralyzed  ones,  a  striking  hypertrophy  of 
these  muscles  is  induced. 

"  Among  other  cases  the  following  have  fallen  under  my  observation : 
"The  two  Barons  von  H.,  twin  brothers,  well-built,  fine  large  men, 
uniformly  healthy,  in  their  eighteenth  year,  simultaneously  fell  sick 
with  the  measles.  These  having  run  an  apparently  favorable  course, 
were  followed  in  both  with  a  paralysis  of  the  legs  inducing  a  constantly 
increasing  emaciation  of  those  parts.  When  I  visited  them,  which  was 
not  till  they  had  reached  their  twenty-fourth  year,  the  circumference 
of  the  thighs  of  each  measured  respectively  twenty  and  twenty-one 
inches,  the  circumference  of  the  calves  ten  and  ten  and  a  half  inches  ; 
the  latter  dimension,  if  the  normal  relation  of  the  thighs  to  the  calves 
be  as  three  to  two,  was  accordingly  four  inches  below  the  true  stand- 
ard. The  glutei  muscles,  on  the  contrary,  as  the  patients  made  all  loco- 
motory  movements  from  the  hip-joint,  were  developed  to  colossal 
proportions,  contrasting  strongly  with  the  emaciated  legs.  Their  walk 
was,  therefore,  very  peculiar.  As  the  legs  could  only  be  used  as  stilts, 
at  every  step  of  the  right  or  left  foot  there  occurred  a  rotary  movement 
from  behind  forward  of  the  right  or  left  thigh,  which  communicated 

1  "Die  Kkctricitiit  in  ilircr  Anwcndung,"  etc.,  Berlin,  18C8.  See  also  my  translation 
of  this  work,  "Electricity  in  its  Relations  to  Practical  Medicine,"  second  American 
edition,  New  York,  1874,  p.  229. 


4G0  DISEASES   OF   THE   SPINAL   CORD. 

itself  to  the  whole  body,  causing  it  to  turn  at  every  step  toward  the 
one  or  the  other  side.  The  extensor  power  of  the  leg-  was  very  limited; 
the  dorsal  extension  of  the  foot  and  the  flexion  of  the  toes  were  not  in 
the  power  of  the  patients,  and  but  a  slight  adduction  of  the  toes  was 
possible;  the  patients  trod  upon  the  outer  borders  of  the  feet,  and  in 
the  mm.  tibialcs,  consequently,  contorted  forms  were  exhibited.  The 
adductors  of  the  thigh  as  well  as  the  muscles  of  the  foot  were  normally 
developed;  en  the  other  hand,  the  extensors  of  the  knee-joint  and  all 
the  muscles  of  the  leg  had  suffered  greatly  in  assimilative  power.  The 
sensibility  of  the  skin  and  muscles  was  perfectly  preserved.  The 
electro-muscular  contractility  was  reduced  in  the  quadriceps  femoris, 
and  altogether  wanting  in  the  mm.  peronei,  the  extensors  digit,  com., 
the  gastroencmii,  etc.;  but  the  adductors  of  the  knee-joint  and  the 
toes  showed  a  weak  reaction." 

It  is,  therefore,  quite  apparent  that  Meyer  had  a  very  distinct  con- 
ception of  the  disease  in  question. 

Since  then  a  number  of  cases  have  been  reported  under  different 
names,  which  are  clearly  instances  of  the  affection  in  question,  and  no 
small  amount  of  confusion  exists  in  regard  to  the  whole  subject,  from 
the  fact  that  unnecessary  refinement  has  been  shown  in  classifying 
them.  Thus,  as  we  have  seen,  Duchenne  describes  two  varieties — an 
acute  anterior  spinal  paralysis  of  the  adult  and  subacute  general 
anterior  spinal  paralysis  of  adults.  This  latter  has,  by  others,  been 
designated  acute  ascending  paralysis.  After  a  full  survey  of  the  sub- 
ject and  careful  study  of  several  cases  of  each,  I  am  very  decidedly  of 
the  opinion  that  these  two  varieties  do  not  essentially  differ  from  each 
other.  The  affection  called  by  Duchenne '  subacute  diffused  general 
spinal  paralysis — a  name  calculated  to  add  greatly  to  the  already 
existing  confusion — is  evidently  acute  general  myelitis.  This  view  rela- 
tive to  the  identity  of  the  two  morbid  states  I  have  taught  for  two 
years  past  to  the  medical  classes  at  the  University  of  New  York.  It  is 
sustained  by  very  cogent  reasoning  by  M.  Petitfils,3  and  is  held  also 
with  some  reservation  by  Dr.  E.  S.  Seguin 3  in  his  excellent  little  mono- 
graph on  the  affection  in  question. 

Symptoms. — The  onset  of  the  disease  is  generally  sudden,  and  is 
usually  characterized  by  pains  in  the  back,  which  radiate  to  the  limbs, 
and  by  the  various  sensations  of  numbness,  especially  in  the  extreme 
peripheric  parts  of  the  body.  There  may  or  may  not  be  fever,  and 
when  it  is  present  it  is  not  ordinarily  excessive.  At  the  same  time 
there  is  loss  of  the  power  of  motion,  varying  in  character  and  degree 
from  the  sudden  and  complete  paralysis  of  all  the  limbs,  to  the  gradual 

1  "L' electrisation  localisee,"  troisieme  ddition,  Paris,  1872. 
8  "Considerations  sur  l'atrophic  aigue  des  cellules  raotrices,"  Paris,  1873,  p.  83. 
8  "Spinal  Paralysis  of  the  Adult:  Acute,  Subacute,  and  Chronic — (Inflammation  of 
the  Motor  Tract  of  the  Spinal  Cord"),  New  York.  1874. 


SPINAL   PARALYSIS   OF   ADULTS.  461 

extension  of  the  akinesis  from  a  part  of  an  extremity  to  one  or  more. 
At  this  early  period,  as  I  have  recently  had  an  opportunity  of  deter- 
mining, by  means  of  Dr.  Lombard's  instrument  for  measuring  differ- 
ences of  temperature,  there  is  an  increase  of  heat  in  the  affected  ex- 
tremities amounting  to  from  2°  to  -4°  Fahr.  From  the  very  first  and 
throughout  the  whole  course  of  the  disease  the  sensibility  ordinarily 
remains  intact,  and  the  pains  which  are  commonly  phenomena  of  the 
initial  part  of  the  primary  stage  disappear  within  the  first  two  or 
three  days,  or  even  earlier,  and  sometimes  are  not  present  at  all. 

The  bladder  and  the  sphincter  ani  generally  remain  unaffected. 
There  are  usually  no  cramps  or  spasmodic  contractions  of  any  of  the 
muscles.  Neither  is  any  feeling  of  constriction  experienced  around  the 
body.  The  electric  contractility  of  the  muscles  is  impaired  at  a  very 
early  stage,  and  generally  goes  on  diminishing  till  at  last  very  strong 
induced  currents  fail  to  cause  any  reaction.  It  is  rare,  however,  that 
the  excitability  to  the  galvanic  current  is  entirely  abolished,  except  in 
long-continued  and  neglected  cases,  and,  even  in  these,  currents  of  great 
intensity  will  often  cause  contractions,  but  the  reactions  of  degenera- 
tion are  well  marked.  At  the  same  time  the  cutaneous  sensibility  to 
all  kinds  of  electrical  stimulation  remains  unimpaired. 

Reflex  contractions  in  all  the  paralyzed  parts  are  difficult,  and  some- 
times impossible  to  excite  from  the  very  beginning. 

The  face  is  rarely  involved.  In  one  of  my  own  cases,  however,  one 
side  was  completely  paralyzed,  so  far  as  the  seventh  pair  of  nerves  was 
concerned,  and  Dr.  Seguin1  has  reported  an  instance  in  which  the 
third  and  facial  nerves  were  both  affected.  Some  of  the  other  symp- 
toms go  to  show  that  this  was  not  an  uncomplicated  case,  and  Dr. 
Seguin's  diagnosis  was  "myelitis  or  degeneration  of  the  anterior  horns 
of  gray  matter  of  the  cord;  the  motor  part  being  involved  from  the 
third  cerebral  nerve  downward,  with  probably  recent  extension  of 
myelitis  to  deeper  parts  of  cord  at  some  points." 

In  the  majority  of  cases  the  paralyzed  parts,  after  a  period  vary- 
ing from  two  or  three  weeks  to  several  months,  begin  to  recover  their 
power,  but  it  usually  happens  that  the  loss  of  motility  remains  in  some 
muscles  as  in  the  infantile  form  of  the  disease.  Atrophy  may  occur 
before  the  retrocession  of  the  paralysis.  Generally,  however,  its  ap- 
pearance i-  firsl  seen  in  those  parts  which  remain  paralyzed,  and  occa- 
sionally it  is  absent  altogether.  In  all  the  cases  collected  and  observed 
by  Seguin,  if  was  a  prominenl  feature;  it  was  wanting  in  one  of  my 
own  cas  is,  thai  above  referred  to  ;  as  h  was  likewise  in  a  very  inter- 
esting instance  reported  by  Dr.  Labadie-Lagrave,'  in  which  the  mus- 
cles of  r  9piration  were  involved,  hut  yef  in  which  recovery  took  place. 

'  (>/>  ■   '  .  '  XXI.,  |>.  1'.'. 

•  M0  d  >1'-  pararj  "    Brochure,  extrait  de  la  G 

H&pUaux,  1870. 


462  DISEASES   OF  THE   SPINAL   CORD. 

The  reduction  of  temperature,  though  marked,  never,  in  my  ex« 
perience,  reaches  the  low  point  observed  in  the  infantile  form.  The 
atrophy  likewise  is  rarely  so  profound.  But  in  the  case  of  a  gentleman 
of  New  Jersey,  in  whom  the  paralysis  began  slowly  in  the  left  lower 
extremity  and  gradually  extended  upward  till  the  medulla  oblongata 
was  involved,  and  death  produced  from  asphyxia,  the  wasting  was  rapid 
and  extensive,  till  at  last  apparently  nothing  of  the  muscular  tissue  re- 
mained in  the  limb  first  affected.  In  this  case  the  right  side  continued 
free  from  the  least  sign  of  paralysis  so  long  as  the  patient  was  under 
my  observation. 

In  some  cases  which  have  been  observed,  the  paralysis  is  first  mani- 
fested in  the  lower  limbs,  and  progressively  advances  upward  till  the 
superior  extremities  are  affected.  Still,  in  some  cases  continuing  its 
progress,  the  medulla  oblongata  is  reached,  and  death  takes  place  by 
asphyxia.  Or  it  may  follow  a  descending  course,  the  superior  extremi- 
ties being  first  attacked,  and  subsequently  the  inferior. 

The  muscles  in  some  of  these  instances  are  very  rapidly  and  pro- 
foundly atrophied,  and  can  be  seen  to  waste  from  day  to  day  in  groups. 

Such  cases  may  be  regarded  as  representing  the  subacute  form  as 
described  by  Duchenne. 

Other  examples  designated  by  the  names  of  acute  progressive  pa- 
ralysis, acute  ascending  paralysis*  etc.,  are  in  reality  like  those  de- 
scribed by  Duchenne  under  the  title  of  subacute  general  diffused  spinal 
paralysis,  and  are  cases  of  general  myelitis.  Of  such  notably  is  the 
instance  reported  by  Iiarley,2  in  which  the  post-mortem  examination 
was  made  by  Lockhart  Clarke,  and  the  lesion  found  to  implicate  not 
only  the  anterior  horns  but  the  posterior,  and  the  antero-lateral  and 
posterior  columns. 

In  no  case  that  has  been  reported  or  that  has  come  under  my  own 
notice  was  there  any  tendency  exhibited  to  the  formation  of  bed-sores. 

From  the  foregoing  account  it  will  be  seen  that  the  more  prominent 
phenomena  observed  in  cases  of  spinal  paralysis  in  the  adult  are  strik- 
ingly like  those  which  characterize  the  infantile  form.  Even  as  regards 
the  results  there  is  no  essential  variation,  except  that  due  to  difference 
of  age.  There  is,  of  course,  in  the  adult  no  arrest  of  development,  and 
the  disposition  to  deformities  is  not  so  great  as  in  the  infant,  but  nev- 
ertheless, as  in  the  first  case  reported  by  Charcot,3  they  may  occur. 

Occasionally,  hyperesthesia  exists.  This  was  the  case  in  two  of 
Seguin's  cases  4 — XX.  and  XXII. — and  to  a  marked  degree  in  that  of 
Labadie-Lagrave.6     Thus,  as  the  latter  remarks  : 

1  Landry,  "  Note  sur  la  paralysie  ascendante  aiguo,"  Gazette  Hebdomadaire,  1850,  pp. 
470,  et  seq. 

4  Lancet,  October  3,  18G8. 

3  "Lecons  sur  les  maladies  du  syst&me  nerveux,"  fas.  iii.,  1874,  p.  173. 

*  Op.  cit.,  pp.  17,  22.  *  Op.  cit.,  p.  6. 


SPINAL  PARALYSIS  OF  ADULTS.  4G3 

"  Besides  the  cutaneous  hyperesthesia,  there  was  a  still  more  de- 
cided muscular  hyperesthesia.  The  lightest  pressure  on  the  muscles 
was  very  painful,  and  caused  the  patient  to  cry  out.  In  addition,  lan- 
cinating1 pains  were  felt  in  the  lumbar  region,  when  the  flexed  thighs 
were  suddenly  extended.  Passive  movements  of  the  lower  extremities 
also  caused  a  certain  amount  of  pain." 

It  is  very  certain  that  many  cases  of  spinal  paralysis  and  atrophy 
occurring  previously  to  the  last  two  or  three  years,  and  reported  under 
other  designations,  were  in  fact  instances  of  spinal  paralysis  of  adults. 
This  is  probably  true,  for  instance,  as  regards  the  "  case  of  acute  mus- 
cular atrophy,"  '  occurring  in  the  London  Hospital  in  the  service  of  Dr. 
Ramskill,  relative  to  which  it  is  stated  that  "  electro-motility  was  ab- 
sent," a  circumstance  not  present  in  progressive  muscular  atrophy. 

A  case  which  forms  the  subject  of  a  clinical  lecture  by  Jaccoud  a  is 
clearly  one  of  inflammation  of  the  anterior  tract  of  gray  matter.  The 
patient,  a  man  seventy  years  of  age,  was  seized  with  pains  and  numb- 
ness in  the  extremities,  with  incoordination.  Shortly  afterward  there 
was  loss  of  power  in  all  four  limbs,  which  progressively  increased  till  at 
last  he  was  unable  to  walk  or  to  use  his  arms.  At  the  same  time  atro- 
phy began  in  the  paralyzed  parts.  Reflex  movements  were  abolished 
and  reflex  excitability  was  either  lost  or  impaired,  in  the  affected  mus- 
cles. There  were  pains  and  some  loss  of  sensibility.  Death  ensued  : 
on  post-mortem  examination  the  spinal  arachnoid  was  found  studded 
with  fibrous  plates,  which  pressed  upon  the  roots  of  the  nerves,  causing 
their  atrophy.  Hence  the  name  of  progressive  nervous  atrophy  which 
Jaccoud  gives  to  the  case.  The  spinal  cord  was  pronounced  healthy, 
but,  as  no  microscopical  examination  was  made  of  it,  the  opportunity 
was  lost  for  discovering  the  real  and  essential  lesion,  the  disease  of  the 
anterior  horns,  which  undoubtedly  existed. 

Some  of  the  cases  which  I  have,  previous  to  the  recognition  of  the 
affection  under  notice,  regarded  as  instances  of  spinal  congestion,  pro- 
gressive muscular  atrophy,  and  antero-lateral  spinal  sclerosis,  were,  I 
have  now  no  doubt,  examples  of  inflammation  of  the  anterior  tract  of 
gray  matter.     Several  of  these  I  have  reported. 

Among  them  is  the  case  of  Rose  Peyton,  who  formed  the  subject  of 
a  clinical  lecture  I  delivered  at  the  Bellevue  Hospital  Medical  College s 
in  the  autumn  of  1870,  and  of  which  my  clinical  assistant,  Dr.  Cross, 
prepared  at  the  time  the  following  report:  "Rose  Peyton,  twenty-seven 
years  of  age,  born  in  Ireland,  mother  of  two  children,  both  of  whom  are 

1  Quoted  from  the  Lancet  in  the  Quarterly  Journal  of  1'xycholoyical  JlcJicine,  vol.  iii., 
1869,  p.  198. 

,uDc  I'atrophie  nerreaie  progressive,"  "  Lccons  decliniqne  mddicale,"  second  edi- 
tion, Paris,  1869,  p.  87'J. 

*  "Clinical  Lectures  on  Diseases  of  the  Nervous  System,"  Quarterly  Journal  of  Psy- 
chological Midicinr,  January,  1871,  p.  22. 


4G4  DISEASES  OF  THE  SPINAL  CORD. 

living;  the  older  has  talipes  valgus,  while  the  younger  is  a  fine,  hearty 
child.  Her  family  is  very  healthy,  and  there  is  no  evidence  of  nervoua 
diseases  either  in  it  or  in  any  of  its  branches,  so  far  as  she  is  aware. 
The  patient  was  a  strong,  active  woman,  and  always  did  her  own  work 
until  twelve  weeks  ago.  In  May  there  was  a  cessation  of  menstruation, 
and  in  July  last  she  was  seized  with  a  deep,  dull,  aching  pain  in  both 
legs,  and  which  appeared  to  her  to  be  in  the  bones.  There  is  no  syphi- 
litic taint  in  her  history.  There  succeeded,  shortly  after,  a  severe  pain 
in  the  back,  which  has  continued  up  to  the  present  time,  but  which  has 
varied  in  intensity.  Soon,  loss  of  motility,  numbness,  and  anassthesia, 
made  their  appearance  in  both  legs,  and  in  the  course  of  two  months 
she  was  totally  unable  to  walk.  At  first,  her  bowels  were  very  costive, 
but  soon  this  condition  was  succeeded  by  incontinence  of  the  rectum, 
which  lasted  for  two  weeks,  varying  in  degree.  There  was  also  reten- 
tion of  urine.  Sensations  of  formication  alternating  with  numbness, 
of  heat  and  cold,  of  pricking  by  pins  and  needles,  were  present  not  only 
in  the  feet  and  toes,  but  also  in  the  hands  and  fingers.  Patient  noticed 
that  on  rising  in  the  morning,  after  a  night's  rest,  her  limbs  were 
weaker,  and  that  she  had  greater  difficulty  in  moving  about.  The 
paralysis,  after  commencing  in  the  lower  extremities,  rapidly  extended 
to  the  upper.  August  25th. — Was  able  to  get  out  of  bed  for  the  first 
time  in  five  weeks,  and  by  means  of  a  chair  could  move  about  a  very 
little.  Since  then  she  had  improved  only  so  much  as  to  be  able  to  come 
to  the  out-door  department  of  the  New  York  State  Hospital  for  Dis- 
eases of  the  Nervous  System,  by  being  supported  by  a  person  on  each 
side,  and  only  then  with  extreme  difficulty.  She  was  admitted  Septem* 
ber  22,  1870,  when  she  was  found  in  the  following  condition  :  Motility 
and  tactile  sensibility  in  both  legs  greatly  impaired,  but  the  right  leg 
is  the  weaker  of  the  two.  Left  hand,  as  measured  by  the  dynamometer, 
is  much  feebler  in  power  than  the  right,  and  this  to  a  more  marked 
degree  than  any  normal  disparity.  Sensations  of  formication,  alternating 
with  numbness,  of  heat  and  cold,  pricking  by  pins  and  needles,  and 
tingling,  still  continued  in  the  feet  and  toes,  as  also  in  the  hands  and 
fingers.  Pain  in  the  back  increased  by  pressure  and  percussion,  but  no 
burning  sensation  on  applying  heat  and  cold.  The  anaesthesia  is  more 
marked  in  the  thighs  than  in  the  legs;  soreness  in  the  soles  of  the  feet; 
bowels  constipated;  bladder  normal;  electro-muscular  contractility  and 
sensibility  greatly  diminished.  No  band  around  the  waist.  No  spasms, 
twitchings,  or  reflex  movements  in  the  legs.  Pain  in  the  lower  ex- 
tremities as  at  first.  Changes  in  the  degree  of  paralysis  from  time  to 
time.  Temperature  diminished.  The  circumference  of  the  legs  is  dimin- 
ished to  a  marked  extent  owing  to  the  atrophy  of  the  muscles.  Heart 
and  lungs  healthy;  urine  not  examined." 

At  the  time,  I  regarded  this  case  as  one  of  spinal  congestion,  and 
this  was  probably  an  associated  condition,  but  it  is  very  evident  that  it 


SPINAL  PARALYSIS   OF  ADULTS.  465 

was  an  instance  of  inflammation  of  the  anterior  tract  of  gray  matter 
chronic  in  character.  The  treatment  by  my  direction  consisted  of  elec- 
tricity and  ergot,  and  a  complete  recovery  was  the  result. 

The  case  of  Elbert  Baxter,  detailed  in  the  same  lecture,  was  prob- 
ably one  of  inflammation  of  the  right  half  of  the  cord  involving  the 
anterior  tract  of  gray  matter  and  right  posterior  column.  There  were 
paralysis  with  atrophy  of  the  right  lower  extremity,  and  marked  anaes- 
thesia and  incoordination  in  the  left.  This  patient  also  recovered  after 
having  been  under  treatment  with  ergot  and  electricity  at  the  New 
York  State  Hospital  for  Diseases  of  the  Nervous  System  for  over  a 
year. 

Another  case,  likewise  a  patient  in  this  hospital,  and  the  subject  of 
another  clinical  lecture,  was  at  that  time,  February  18, 1871,  regarded  by 
me  as  an  instance  of  progressive  muscular  atrophy  beginning  with  con- 
gestion. It  is  Cases  X.  and  XVII.,  of  those  collected  by  Dr.  Seguin,1 
who  saw  the  patient  two  days  before  I  did,  and  who  then  considered  it 
an  example  of  spinal  congestion.  It  is  also  briefly  cited  in  the  former 
editions  of  this  work,2  and  in  full  in  a  subsequent  publication.' 

The  affection  began  with  pain  in  the  back  and  sharp,  shooting  pains 
in  the  legs,  attended  with  weakness.  There  was  also,  at  first,  some 
headache,  vertigo,  confusion  of  ideas,  etc.  Numbness  and  loss  of  power 
existed  in  both  the  upper  and  lower  extremities.  Subsequently,  the 
anaesthesia  and  paralysis  of  the  upper  extremities  disappeared.  Six 
months  afterward  the  head-symptoms  recurred,  and  there  were  super- 
added fibrillary  contractions  in  both  arms  and  legs,  with  a  return  of  the 
numbness.  The  paralysis  of  the  lower  limbs  increased  to  such  an 
extent,  that  the  patient  was  obliged  to  use  crutches,  and  six  weeks  later 
he  was  confined  to  bed,  unable  to  move  any  part  of  his  body  but  his 
head.  The  bladder  and  its  sphincter  were  also  weakened,  though  he 
did  not  lose  control  of  them.  The  paralysis  of  the  arms  again  disap- 
peared, but  it  remained  in  the  legs,  and  he  now  noticed  that  they  began 
to  be  atrophied,  and  this  condition  went  on  advancing.  For  three  years 
he  did  not  walk  at  all,  and  during  this  time  the  fibrillary  contractions 
continued  in  the  legs,  though  to  a  diminished  extent.  He  then  gradu- 
ally reacquired  the  power  to  walk  with  a  crutch.  At  the  time  of  his 
admission  to  the  hospital  his  condition,  as  ascertained  by  Dr.  Cross,  was 
as  follows  :  * 

"In  the  legs  the  extensors,  together  with  the  gastroencmii  and  so- 
lei  muscles,  were  found  to  have  almost  disappeared,  while  the  atrophy 
in  the  thigh   was   distinctly  visible,  and  this  loss  of   power  had  been 

1  <>/>.  cit.,  pp.  8  and  10.     See  note  of  Dr.  Seguin  appended  to  p.  11  of  his  Memoir. 

*  Former  editions,  p.  606. 

'"Lectures  on  Diseases  of  the  Nervous  System,"  New  York,  1874,  p.  147 — historj 
prepared  by  Dr.  Cross. 

*  "Clinical  Lectures,"  p.  150. 

31 


466  DISEASES   OF   THE   SPINAL   CORD. 

directly  proportioned  to  the  extent  of  the  atrophy.  The  gait  of  this 
patient  was  also  highly  characteristic  of  the  disease  from  which  he  was 
suffering.  In  walking  he  lifted  his  feet  high  from  the  ground  through 
the  action  of  the  flexors  of  the  thigh  upon  the  pelvis,  in  order  to  clear  his 
toes,  which  drooped  to  an  extreme  degree — and  his  knees  were  in  this 
way  bent  to  a  greater  extent  than  usual.  The  legs  were  very  much 
reduced  in  size,  and  the  loss  of  muscular  fibre  was  quite  apparent  from 
the  greatly  diminished  electric  contractility  in  these  parts.  There  was 
no  atrophy  to  be  discerned  in  any  other  part  of  the  body,  nor  did  the 
patient  have  any  head-symptoms  whatever,  nor  had  he  any  loss  of  motil- 
ity, or  any  abnormal  sensations  in  his  upper  limbs.  His  bowels  were 
regular,  and  he  had  no  trouble  with  his  bladder.  There  was  no  loss  of 
sensibility,  nor  were  there  anjr  sensations  of  numbness  in  the  legs.  His 
heart  and  lungs  were  in  a  healthy  state.  The  reflex  excitability  was 
diminished  in  the  lower  extremities,  as  was  likewise  the  tenrperature, 
and  the  capillary  circulation  was  very  sluggish,  as  was  demonstrated  by 
the  decrease  of  temperature,  which  was  several  degrees  below  the  nor- 
mal standard,  and  the  effect  of  pressure.  There  were  no  fibrillary  con- 
tractions present,  nor  had  the  patient  experienced  any  electric-like 
pains,  cramps,  jerkings,  or  other  abnormal  sensations  for  some  time. 
The  outlines  of  the  fibuke  and  tibiae,  together  with  the  knee-joints,  were 
distinctly  visible,  owing  to  the  destruction  of  the  muscles  on  the  ante- 
rior surface  of  the  leg,  while  the  posterior  aspect  of  the  calf  was  flat- 
tened from  a  like  cause.  His  back-ache  had  completely  disappeared, 
but,  although  he  felt  well  and  suffered  no  pain,  he  appreciated  the 
gradual  loss  of  power  in  his  lower  extremities.  His  appetite  was  good, 
and  his  mind  was  very  active." 

In  his  recent  memoir,  Dr.  Seguin  classes  this  case  as  one  of  spinal 
paralysis  of  the  adult,  in  which  opinion  I  entirely  coincide.  At  the 
time  I  described  it,  the  disease  under  notice  was  not  distinctly  recog- 
nized, and  certainly  the  resemblance  to  progressive  muscular  atrophy 
was  very  great.  With  locomotor  ataxia,  to  which  affection  Charcot ' 
assigns  it,  it  has  scarcely  any  thing  in  common. 

The  cut  (Fig.  45),  owing  to  the  position  of  the  patient  when  the 
photograph  was  taken,  does  not  show  very  well  the  effect  of  the  disease 
in  the  legs,  but  the  atrophy  of  the  thighs  is  distinctly  indicated. 

Two  cases  which  I  had  regarded l  as  instances  of  "  antero-lateral 
spinal  sclerosis "  were  very  probably  examples  of  inflammation  of  the 
anterior  tract  of  gray  matter.  In  one  of  these,  a  gentleman  whom  I 
first  saw  in  consultation  with  my  friend  Dr.  Walter  F.  Atlee,  of  Phila- 
delphia, and  who  was,  subsequently,  for  a  long  time  under  my  imme- 
diate charge,  the  lesion  was  in  the  beginning  confined  to  the  very 
lowest  part  of  the  spinal  cord.    Gradually  the  disease  extended  upward 

1  "A  Treatise  on  Diseases  of  the  Nervous  System,"  New  York,  1871 — and  subsequent 
editions,  pp.  475,  476. 


SPINAL   PARALYSIS   OF   ADULTS. 


467 


until  at  last,  after  three  years,  the  muscles  of  respiration  and  of  deglu- 
tition became  implicated,  and  death  took  place.  But  for  several  months 
before  this  the  patient  was  unable  to  use  either  legs  or  arms,  or  even  to 
sit  up.     At  no  time,  however,  was  the  bladder  deranged  in  any  respect, 


Fig.  45. 


and  at  no  time  were  there  pains  or  spasmodic  action  of  the  muscles. 
The  cutaneous  sensibility  was  scarcely  affected,  and  the  atrophy,  though 
extensive,  was  not  profound,  and  did  not  strike  me  at  the  time  as 
being  very  active  in  character. 

The  other  case  was  that  of  a  distinguished  legal  gentleman  of  New 
Orleans,  sent  to  me  by  my  friend  Dr.  Cabell,  of  the  University  c  I  Vir- 
ginia. There  was  a  gradual  extension  of  the  disease  without  any  at- 
tendant pains,  anaesthesia,  or  muscular  contractions,  except  to  a  slight 
extent  at  first.  In  this  instance  also  the  bladder  and  rectum  escaped. 
This  case  resisted  all  treatment.  The  patient  finally  went  abroad,  and 
died  soon  afterward  in  London.  The  atrophy  was  not  a  prominent 
feature. 

In  another  case,  that  of  a  gentleman  from  New  Jersey,  there  was  a 
similar  condition  of  paralysis,  involving,  however,  only  one  lateral  half 
of  the  body,  and  beginning  in  the  leg.     In  this  case  the  atrophy  was  of 


468  DISEASES   OF   THE   SPINAL   CORD. 

the  most  active  character,  advancing  pari fpassu  with  the  paralysis. 
The  flexors  and  extensors  of  the  foot,  and  the  flexors  of  the  leg,  were 
almost  entirely  destroyed  when  the  patient  came  under  my  observa- 
tion. Before  I  saw  him,  however,  he  had  consulted  several  distinguished 
medical  gentlemen,  who  had  treated  his  case  as  one  of  tumor  of  the 
cord  or  of  the  vertebral  column.  This  case  has  already  been  cited  on 
page  474,  and  is  noticed  in  the  previous  editions  of  this  work.1 

In  regard  to  these  three  cases,  I  stated  in  1871,3  "Such  cases  as  the 
foregoing,  and  several  others  which  have  come  under  my  notice,  are 
doubtless  to  be  classed  with  many  of  those  placed  under  the  head  of 
what  Duchenne  has  called  general  spinal  paralysis." 

Since  1873  I  have  had  the  opportunity  of  witnessing  many  cases  of 
spinal  paralysis  of  adults.  Some  of  the  more  striking  of  these  will  be 
noticed  under  other  divisions  of  this  section. 

Causes. — In  many  cases  of  spinal  paralysis  of  adults,  the  disease  is 
clearly  the  result  of  cold,  either  applied  directly  to  the  back  as  in  lying 
on  cold,  damp  ground,  or  from  refrigeration  of  some  part  of  the  surface 
of  the  body.  Relative  to  this  last  influence,  Frinberg 8  has  performed 
an  experiment  which,  if  confirmed  in  its  results,  will  be  of  a  very  in- 
structive character.  He  shaved  off  the  hair  from  the  skin  of  a  rabbit 
and  on  the  unprotected  skin  threw  a  jet  of  the  vapor  of  ether  by  means 
of  Richardson's  apparatus.  Three  days  subsequently  he  repeated  this 
operation.  About  a  month  afterward  the  animal  was  attacked  with  in- 
continence of  urine  and  paraplegia,  and  died  in  a  few  days.  On  post- 
mortem examination  the  whole  length  of  the  spinal  cord  was  found  in- 
flamed. There  was  in  fact  general  acute  myelitis.  In  regard  to  this 
experiment,  I  can  adopt  the  language  of  Vulpian,4  who  says  : 

"  This  experiment  would  be  very  valuable  if  the  results  obtained  had 
been  observed  with  a  certain  number  of  other  animals  treated  in  the 
same  manner.  Till  then  we  may  be  permitted  to  doubt  if  there  really 
was  the  relation  of  cause  and  effect  between  the  refrigeration  of  the 
skin  by  the  ether-spray  and  the  paraplegia  which  made  its  appearance 
a  month  later." 

Bernhardt's  B  case  ensued  upon  exposure  to  cold,  as  did  several  of 
Seguin's,  and  five  in  my  own  experience.  Meyer's "  two  cases  followed 
close  on  measles.  In  Rose  Peyton,  whose  case  I  have  related,  sudden 
suppression  of  menstruation  appeared  to  be  the  cause  ;  in  a  number  of 
others,  blows  and  falls  were  alleged  as  causes,  and  in  others  venereal 
excesses,  dysentery,  syphilis,  and  violent  muscular  efforts,  seem  to  have 
been  the  exciting  agencies.     In  the  majority  of  cases,   however,  no 

1  Op.  cil.,  p.  476.  2  Previous  editions  of  this  work,  p.  470. 

■  "Ucber  Reflexlahmungen,"  Bo-Jin.  klin.  Wochewtchrift,  1871,  Nos.  41,  42,  44,  45. 

4  "  Lecons  sur  l'appareil  vaso-moteur,"  Paris,  1S69,  tome  ii.,  p.  88. 

5  "  Ueber  eine  der  Spinalen-Kinderliilimung  iihnliche  Affection  Erwachsener,"  Ar-hiv 
fur  Psychiatric  mid  Ncrvcnkrankheitcn,  B.  iv.,  1873.  6  Op.  cit.,  p.  229. 


SPINAL   PARALYSIS   OF   ADULTS.  469 

cause  can  be  discovered.  Such  at  least  has  been  the  fact  with  the 
instances  that  have  come  under  my  own  observation. 

Diagnosis, — Spinal  paralysis  of  adults  is  to  be  recognized  by  the 
facts  that  the  paralysis  is  often  extensive  in  the  first  place,  and  then 
becomes  restricted,  or  that  it  begins  in  a  limited  portion  of  the  body, 
usually  in  one  or  both  of  the  lower  extremities  and  then  advances  ;  that 
the  paralysis  always  precedes  the  atrophy  ;  that  the  reflex  excitability 
is  somewhat  impaired  or  is  abolished  ;  that  the  electro-muscular  con- 
tractility is  diminished  and  the  "reactions  of  degeneration"  can  be 
obtained  ;  that  there  are  no  bed-sores  ;  that  the  disturbances  of  sensi- 
bility are  not  usually  prominent  features  ;  and  that  the  bladder  and 
rectum  generally  escape. 

It  has  been  often  confounded  with  progressive  muscular  atrophy, 
but  attention  to  the  features  above  stated  will  prevent  mistakes  of  the 
kind.  In  progressive  muscular  atrophy,  it  must  be  borne  in  mind  that 
the  atrophy  is  the  essential  feature,  and  that  the  loss  of  power  results 
from  the  diminished  size  of  the  muscles,  while  it  is  the  most  rare  oc- 
currence to  tind  the  "  reactions  of  degeneration  "  present. 

In  acute  general  myelitis  the  paralysis  of  the  bladder  and  sphincter 
ani,  the  tendency  to  bed-sores,  the  spasmodic  movements  of  the  limbs, 
the  great  disturbances  of  sensibility,  the  sensation  of  constriction  around 
the  body,  and  the  greater  constitutional  commotion,  will  serve  for  the 
identification  of  the  disease.  In  the  partial  form  of  acute  myelitis  the 
distinctive  features  are  equally  as  marked. 

Hallopeau l  has  reported  a  number  of  cases  under  the  head  of  chronic 
diffused  myelitis,  which  were  undoubtedly  instances  of  spinal  paralysis 
of  adults,  judging  both  from  their  symptoms  and  morbid  anatomy,  and 
the  author  admits  as  much  when  he  says  : a 

"  The  remarkable  lesions  [brown  discoloration,  no  microscopical  ex- 
amination being  made]  which  we  found  in  the  anterior  horns  permit  us 
to  think  that,  as  in  the  cases  of  MM.  Charcot  and  Joffroy,  histological 
alterations  would  have  been  discovered." 

The  distinction  between  the  acute,  the  subacute,  and  the  chronic 
forms  of  spinal  paralysis  of  adults  is  not  one  of  kind  but  only  of  de- 
gree, and  the  same  may  be  said  of  the  acute  ascending  paralysis  of  Lan- 
dry, on  which  I  have  already  insisted.  The  fact  that  in  the  latter  form 
of  the  disease  the  respiratory  muscles  are  affected,  is  of  course  only  due 
to  the  circumstance  that  the  morbid  process  has  reached  the  medulla 
oblongata.  In  regard  to  this  variety,  Dr.  Seguin  says  :  "There  is  an 
affection  running  its  course  in  ten  or  twenty  days,  oharaoterized  by 
symptoms  almost  identical  with  those  of  subacute  spinal  palsy.  There 
is  an  akinesia,  without  much  anaesthesia,  first  appearing  in  the  feet  and 
logs,  then  ascending  and  involving  the  entire  trunk  and  liml>s,  produo- 

1  "  £tu(!c9  sur  les  mytflites  chroniques  diffhses,"  Archives  Generates,  1871-'72. 
»  ()],.  <■!/.,  tome  i.,  1872,  p.  72. 


470  DISEASES   OF   THE   SPINAL   CORD. 

ing,  in  nearly  all  cases,  death  by  asphyxia.  It  is  upon  this  palsy  of  the 
respiratory  muscles  that  the  diagnosis  of  this  most  fatal  disease,  acute 
ascending  paralysis,  is  to  be  made  from  spinal  paralysis." 

Now,  if  in  any  case  the  progress  of  the  disease  had  been  arrested  at 
a  point  of  the  spinal  cord  half  an  inch  below  the  decussation  of  the  an- 
terior columns,  the  diagnostic  mark  of  Dr.  Seguin  would  have  been 
absent,  and  the  distinction  between  the  form  in  question  and  spinal  pa- 
ralysis of  adults  could  not  have  been  made.  The  mere  fact  of  the  im- 
plication of  the  respiratory  nerves  cannot,  in  my  opinion,  be  made  a 
ground  for  assuming  a  separate,  nosological  position  for  acute  ascend- 
ing paralysis  any  more;  than  the  circumstance  of  the  brachial  plexus  be- 
ing reached  in  any  case  should  make  a  distinct  form.  Dr.  Seguin  does 
not  appear  to  recognize  the  fact  that  the  acute  ascending  paralysis  of 
Landry  is  identical  with  the  subacute  general  anterior  spinal  paralysis 
of  adults,  although  he  very  distinctly  admits  the  relationship. 

Petitfils  '  has  entered  at  length  into  the  consideration  of  the  question 
of  the  identity  of  the  acute  and  subacute  forms,  and  has  very  satisfac- 
torily shown,  both  from  the  symptoms  and  the  morbid  anatomy,  that 
no  essential  difference  between  them  exists. 

From  spinal  congestion  the  spinal  paralysis  of  adults  is  discriminated 
by  the  facts  that,  in  the  former  the  sphincters  are  usually  affected,  that 
the  paralysis  is  not  generally  complete  in  any  part  of  the  body,  by  the 
absence  of  atrophy,  and  by  the  general  presence  of  disturbances  of  vis- 
ceral functions.  In  the  first  stage,  however,  of  either  affection,  it  must 
be  admitted  that  very  striking  resemblances  exist,  and  time  may  be 
necessary  for  the  diagnosis  to  be  made  with  accuracy.  Thus,  in  a  case 
which  I  saw  a  few  days  since,  in  consultation  with  Dr.  Newcomb  of  this 
city,  there  had  been,  in  the  first  place,  a  set  of  symptoms  present  which, 
had  I  then  seen  the  patient,  would  have  induced  me  to  regard  it  as  one 
of  spinal  congestion.  When  the  man,  a  stage-carpenter,  came  to  me, 
however,  the  paralysis  and  atrophy  of  the  right  lower  extremity,  the 
diminished  temperature  of  that  limb,  and  the  absence  of  bladder- 
troubles,  left  no  doubt  on  my  mind  relative  to  the  case  being  one  of 
spinal  paralysis  in  the  adult. 

A  case  reported  by  Dr.  Cuming,9  of  Belfast,  which  presented  all  the 
essential  features  of  spinal  paralysis  of  adults,  was  regarded  by  him  as 
one  of  spinal  congestion.  The  patient,  a  man  aged  forty,  observed  on 
a  cold  night  that  his  hands  had  become  numb  and  white,  and  when  he 
reached  home  he  had  not  the  use  of  them.  A  few  days  afterward  he 
fell  asleep  on  a  cold  wall,  and  when  he  awoke  found  the  numbness  in* 
creased.     In  a  few  days  he  was  entirely  deprived  of  the  power  of  mo* 

1  "  Considerations  sur  l'atrophie  aigue  des  cellules  motrices,"  Paris,  1873,  p.  83. 

1  "  Case  of  Extensive  Paralysis  from  Morbid  Condition  of  the  Spinal  Cord,  probablj 
Congestion,"  Transactions  of  Ulster  Medical  Society,  Dublin  Quarterly  Journal  of  Medi 
wl  Scicnre.  vol.  xlvii.,  18C9,  p.  471. 


SPINAL  PARALYSIS   OF  ADULTS.  471 

tion  in  all  parts  below  the  neck.  But  he  soon  began  to  regain  the  use 
of  his  limbs,  and  at  the  end  of  two  years  could  walk  well.  The  upper 
extremities  were,  however,  wasted,  and  he  had  the  main  en  griffe. 

The  diagnosis,  therefore,  should  not  be  hastily  made. 

Prognosis. — So  long  as  the  lesion  does  not  attain  to  the  height  of 
the  respiratory  nerves,  the  prognosis,  as  regards  the  life  of  the  patient, 
is  not  unfavorable.  Indeed,  recovery,  with  a  more  or  less  extensive  loss 
of  power,  with  atrophy  and  deformity,  is  the  rule,  and  in  some  cases 
there  is  a  complete  restoration  of  motor  power  and  muscular  integrity. 
Even  when  the  morbid  process  reaches  the  height  of  the  respiratory 
nerves,  life  may  be  preserved,  and  complete  restoration  may  take  place. 
This  was  the  case  with  the  instance  already  cited  reported  by  M.  La- 
badie-Lagrave,  and  in  two  in  my  own  experience,  which  will  be  fully 
cited  under  the  head  of  treatment.  Sometimes  the  process  of  recovery 
begins  within  a  few  days,  and  goes  on  uninterruptedly  till  complete 
restoration  is  the  result. 

When  seen  at  a  later  stage,  when  the  paralysis  and  atrophy  are 
limited,  the  prospect  of  cure  or  improvement  depends  altogether  on  the 
condition  of  the  muscles  as  regards  their  electric  contractility.  If  the 
affected  muscles  can  be  made  to  contract  with  either  the  induced  or 
primary  current,  recovery  will,  in  all  probability,  take  place.  But,  when 
this  action  cannot  be  brought  about,  there  is  no  hope.  The  principles 
of  the  prognosis  are,  therefore,  identical  with  those  which  exist  in  the 
infantile  form  of  the  disease. 

Morbid  Anatomy  and  Pathology. — There  is  not  much  to  add  under 
this  head  to  the  remarks  made  on  the  same  subject  in  regard  to  infan- 
tile spinal  paralysis.  The  characteristics  of  the  disease  have,  as  we  have 
seen,  sufficed  to  place  the  lesion  in  the  anterior  tract  of  gray  matter,  and 
this  theory,  based  upon  physiology  and  the  analogy  of  the  affection 
with  infantile  spinal  paralysis,  has  been  definitely  confirmed  by  post- 
mortem research  within  the  past  three  years  by  Gombault,1  one  of  the 
pupils  of  the  Salpetriere. 

The  patient,  aged  sixty-seven  on  the  1st  of  January,  1865,  was 
seized  suddenly  with  a  paralysis  of  all  four  extremities,  beginning  in 
her  legs  and  extending  to  the  arms  as  a  numbness  and  heaviness. 
Within  half  an  hour  she  could  not  stand.  There  were  no  antecedent 
phenomena,  she  having  been  in  perfect  health  up  to  the  moment  of  the 
attack.  There  was  no  paralysis  of  the  tongue,  muscles  of  deglutition, 
or  respiration.  The  bladder  and  rectum  were  also  unaffected,  and  the 
cutaneous  sensibility  remained  intact. 

The  paralysis  of  the  limbs  soon  became  complete,  and  in  fifteen  days 
she  was  taken  to  the  hospital.  There  was  slight  febrile  disturbance, 
but  at  no  time  were  there  bed-sores. 

1  "Note  flur  un  caa  do  parar/sie  spinale  <k>  I'adulte  suiyi  d'autopsie,"  Arehitm  it  I'hu- 
liologie,  tome  v.,  1873,  p.  80. 


472  DISEASES   OF   THE   SPINAL   CORD. 

After  two  years  passed  in  complete  immobility,  the  patient  recov- 
ered, to  some  extent,  the  use  of  her  limbs.  The  amendment  began  in 
the  upper  extremities.  When  she  entered  the  Salpetriere,  five  and 
a  half  years  after  the  inception  of  the  disease,  she  could  walk  imper- 
fectly with  a  cane.  During-  the  first  year  of  her  stay  in  the  hospital  she 
improved  so  that  she  was  able  to  dress  herself,  and  to  take  short  walks 
in  the  court-yard. 

On  the  13th  of  May,  1872,  examination  showed  that  the  thenar  emi- 
nences had  entirely  disappeared,  the  interosseous  muscles  were  atro- 
phied, there  was  the  main  en  griffe  /  the  muscles  of  the  forearms,  arms, 
shoulders,  neck,  and  chest,  were  atrophied. 

In  the  lower  extremities  the  left  calf  was  most  atrophied,  and  was 
soft  and  flabby  ;  the  thighs  were  unaffected. 

The  electro-muscular  contractility  was  entirely  abolished  in  the  hands 
and  forearms,  impaired  in  other  parts  of  the  upper  extremities,  and  in 
the  legs.     The  cutaneous  sensibility  was  preserved. 

The  patient  soon  afterward  died  of  another  disease. 

On  post-mortem  examination  the  membranes  of  the  brain  and  cord 
were  found  to  be  healthy,  and  to  the  naked  eye  there  was  no  lesion  of 
either  of  these  organs. 

The  histological  examination  of  the  spinal  cord  was  made  after 
hardening  in  solution  of  chromic  acid  and  coloring  with  carmine. 

The  white  substance  throughout  all  its  extent  exhibited  no  traces  of 
disease.  Only  the  columns  of  horizontal  fibres  which  emerge  from  the 
anterior  horns  to  form  the  fibres  of  origin  of  the  anterior  roots  showed 
a  notable  diminution  in  size.  The  posterior  commissure  and  posterior 
horns  were  normal.  The  lesion  was  almost  entirely  confined  to  the 
area  of  the  anterior  horns,  and  here  it  only  concerned  the  large  nerve- 
cells  called  motor-cells.  The  walls  of  the  vessels  had  suffered  no  change; 
they  were  of  normal  thickness,  and  the  sheath  was  free  from  granular 
bodies.  Moreover,  there  was  not  in  the  neuroglia  any  trace  of  the  ex- 
istence of  an  irritative  process  such  as  a  proliferation  of  the  neuroglia. 

As  to  the  alteration  of  the  nerve-cells,  it  was  such  as  is  met  with  in 
progressive  atrophy  of  these  elements — yellow  pigmentation.  The  le- 
sion was  diffused;  it  had  struck  here  and  there  the  nervous  elements,  of 
which  a  certain  number  had  disappeared,  for  in  some  sections  only  fif- 
teen or  twenty  could  be  counted. 

The  cells  which  did  not  exhibit  this  yellow  pigmentation  were 
nevertheless  reduced  in  size. 

This  was  the  first  full  investigation  made  relative  to  the  morbid 
anatomy  of  spinal  paralysis  of  adults;  but,  previous  to  Gombault's  re- 
searches an  examination  of  a  patient  who  had  died  of  ascending  paraly- 
sis, and  in  whom  lesions  of  the  anterior  horns  were  discovered,  was  re 
ported  by  Chalret.1 

1  "Those  do  Paris,"  1872,  cited  by  Gombault. 


SPINAL   PARALYSIS   OF   ADULTS.  473 

The  data  are,  therefore,  quite  sufficient  to  enable  us  to  place  spinal 
paralysis  of  adults  in  a  definite  patho-anatomical  position  as  depending 
upon  inflammation  of  the  anterior  tract  of  gray  matter  and  the  conse- 
quent atrophy  and  disappearance  of  the  cells  constituting  its  nervous 
elements. 

In  regard  to  the  questions  entering  into  the  pathology  of  the  dis- 
ease under  notice  there  is  nothing  to  bring  forward  in  addition  to  the 
facts  and  arguments  already  adduced  under  the  head  of  infantile  spinal 
paralysis. 

Treatment. — The  treatment  of  spinal  paralysis  of  adults  admits  of 
division  into  two  parts,  that  which  is  proper  for  the  first  or  acute  stage, 
and  that  advisable  for  the  second  or  chronic  stage. 

I  have  had  the  opportunity  of  treating  four  cases  of  the  disease  in 
question  from  the  very  beginning,  with  the  result  in  each  case  of  arrest- 
ing the  progress  of  the  disease  and  preventing  any  subsequent  atrophy 
of  the  limbs.  Two  of  these  were  of  the  most  severe  type  of  this  affec- 
tion, and  I  therefore  report  them  with  some  degree  of  fullness,  as  ex- 
emplifying the  therapeutical  principles  which  in  my  opinion  should 
govern. 

A.  G.  S.,  aged  about  thirty-five,  after  rising  one  morning  and 
moving  about  the  room,  felt  a  slight  degree  of  weakness  in  both  lower 
extremities.  This  increased  through  the  day,  and  by  night  he  was  un- 
able to  stand.  The  next  morning  he  felt  similar  weakness  in  both  arms 
and  in  a  few  hours  was  deprived  of  their  use.  He  was  out  of  the  city 
at  the  time,  but  he  was  brought  here,  and  I  saw  him  on  the  fourth  day. 
He  was  then  perfectly  helpless  from  complete  paralysis  of  all  four 
limbs.  There  were  no  aberrations  of  sensibility,  no  paralysis  of  the 
bladder  or  sphincters,  no  motor  spasms  anywhere.  Reflex  excitability 
was  abolished  in  all  the  paralyzed  parts,  and  the  electro-muscular  con- 
tractility was  greatly  diminished  especially  in  the  muscles  of  the  legs. 
The  breathing,  deglutition,  articulation,  and  motility  of  the  neck  and 
face,  were  unaffected.  The  mind  was  as  clear  as  ever.  There  had  been 
slight  fever,  but  this  had  disappeared  when  he  came  under  my  observa- 
tion.    There  was  no  history  of  syphilis. 

I  immediately  began  the  treatment  with  the  iodide  of  potassium  in 
doses  of  ten  grains  three  times  a  day,  increased  gradually,  and  the 
fluid-extract  of  ergot  in  doses  of  a  drachm,  to  be  taken  also  three  times 
a  day. 

( )n  the  following  morning  there  was  some  difficulty  of  respiration 
and  of  deglutition,  and  the  movements  of  the  tongue  were  a  little  awk- 
ward. The  irregularity  and  shortness  of  breathing  increased  through 
the  day  and  night,  and  when  1  s;iw  him  the  next  morning  there  was 
great  discomfort  on  this  account.  The  action  of  the  heart  was  also 
considerably  disturbed,  and  there  were  frequent  interruptions  in  the 
pulse.     On  the  seventh  day  <>f  the  disease  he  suddenly  became  para- 


474  DISEASES   OF  THE   SPINAL  CORD. 

lyzed  on  both  sides  of  the  face,  the  right  being  more  severely  af- 
fected. 

During  all  this  time  the  iodide  of  potassium  and  ergot  had  been  per- 
sistently given,  the  latter,  on  the  appearance  of  the  bulbar  symptoms, 
having  been  increased  to  two  drachms  four  times  daily. 

On  the  ninth  day  of  the  disease  there  was  a  slight  amelioration  in 
the  phenomena  due  to  the  implication  of  the  medulla  oblongata.  The 
respiration  became  easier,  the  deglutition  less  difficult,  the  articulation 
more  distinct,  and  the  facial  paralysis  of  the  left  side  began  to  disap- 
pear. He  was  able  to  close  the  eye  of  that  side  and  to  elevate  and 
corrugate  the  brows. 

On  the  tenth  day  the  facial  paralysis  of  both  sides  had  nearly  disap- 
peared, and  the  patient  was  able  to  breathe  freely,  to  talk  well,  and  to 
swallow  without  inconvenience.  There  was  also  a  slight  return  of 
motility  in  the  lower  extremities.  The  toes  could  be  moved  and  the 
feet  flexed. 

The  galvanic  current,  interrupted  rapidly,  was  now  applied  to  the 
muscles  of  both  upper  and  lower  extremities  for  half  an  hour  every  day, 
at  the  same  time  that  the  internal  medication  was  continued.  The  limbs 
were  also  well  kneaded,  and  passive  motions  made  with  them  frequently. 

On  the  thirteenth  day  his  condition  was  as  follows  :  He  could  move 
both  lower  extremities  while  lying  in  bed — performing  with  slowness, 
but  yet  with  precision,  all  the  movements  of  which  the  parts  were 
capable.  The  arms  could  not  yet  be  moved,  but  he  could  slightly 
extend  and  flex  the  fingers  of  both  hands.  The  bulbar  symptoms  had 
entirely  disappeared.  Reflex  excitability  and  electro-muscular  contrac- 
tility were  good,  except  that  it  required  strong  galvanic  currents  to 
cause  contractions  in  the  anterior  tibial  and  peroneal  muscles  of  both 
legs.  All  the  other  muscles  reacted  well  to  the  faradaic  current.  The 
ergot  and  iodide  of  potassium  were  now  discontinued. 

His  improvement  went  on,  and  by  the  end  of  the  fourth  month  he 
could  walk  a  mile  or  more,  and  use  his  hands  and  arms  well.  There  was 
slight  atrophy  of  the  muscles  of  the  calves,  but  nowhere  else.  The 
faradaic  current  was  still  employed  daily,  and  under  its  use  he  became 
stronger,  till  at  the  end  of  a  year  he  was  not  conscious  of  any  weakness 
in  any  part  of  his  body.  He  has  continued  and  now  is  perfectly  well, 
and  was  kind  enough  to  allow  me  to  make  him  the  subject  of  a  clinical 
lecture  a  few  days  ago  at  the  University  Medical  College. 

B.  B.,  aged  forty-five,  was  attacked  with  gradually-increasing  pa- 
ralysis of  the  right  side,  beginning  in  the  leg,  and  gradually  advancing 
during  several  months,  till  it  involved  the  whole  of  the  lower  extremity 
and  arm.  At  no  time,  however,  was  the  loss  of  power  complete.  He 
went  to  the  Warm  Springs  of  Arkansas,  but  did  not  improve.  Return- 
ing to  New  York  in  April,  1875,  and  his  disease  becoming  worse,  I  was 
requested  to  take  charge  of  his  case. 


SPINAL   PARALYSIS   OF   ADILTS.  475 

When  I  saw  him  there  was  such  a  degree  of  paralysis  of  the  right 
•ower  extremity  that  he  was  unable  to  walk  without  assistance — the 
arm  of  that  side  was  nearly  useless.  The  respiration  was  labored  and 
irregular  ;  he  was  almost  unable  to  swallow,  and  would  not  eat,  on 
account  of  the  great  distress  produced  by  all  attempts  at  deglutition — 
the  tongue  could  not  be  protruded,  and  his  articulation  was  unintelligible. 
Owing  to  his  inability  to  swallow,  the  saliva  ran  in  streams  from  his 
mouth,  and,  as  he  could  not  cough  without  great  and  painful  effort,  the 
mucus  accumulated  in  his  air-passages,  and  caused  danger  of  suffoca- 
tion. It  was  removed  from  time  to  time  from  the  pharynx  by  the 
fingers  of  his  nurse.     There  was  moderate  febrile  excitement. 

Although  the  paralysis  was  more  marked  on  the  right  side,  I  ascer- 
tained that  the  left  was  also  affected.  Tickling  the  soles  of  the  feet 
caused  no  reflex  movements.  Electro-muscular  contractility  was  greatly 
impaired  on  the  right  side,  and  weakened  quite  notably  on  the  left. 
There  was  no  facial  paralysis  ;  no  bladder  or  sphincter  trouble  ;  no 
bed-sores  ;  no  derangement  of  sensibility  ;  no  pains,  and  no  muscular 
spasms. 

At  no  time  had  there  been  any  mental  disturbance,  except  great 
emotional  weakness  and  irritability  of  temper.  The  intellect  was  per- 
fectly intact;  the  memory  perfect. 

The  iodide  of  potassium  was  given  as  in  the  previous  case,  but  was 
combined  with  the  bromide  in  doses  of  fifteen  grains.  Ergot,  in  the 
form  of  the  fluid-extract,  was  also  administered.  I  requested  my  friend 
Dr.  Clinton  Wagner  to  make  a  careful  examination  of  the  throat,  and 
to  take  charge  of  him,  so  far  as  the  immediate  management  of  his 
throat-symptoms  was  concerned.  He  found  the  fauces,  pharynx,  and 
larynx  congested,  and  the  vocal  cords  partially  paralyzed.  He  recom- 
mended steam  inhalations,  and  they  were  used,  with  the  effect  of  giving 
great  relief  by  detaching  the  mucus  and  rendering  it  more  fluid. 

As  the  difficulty  of  swallowing  increased,  I  made  preparations  to 
feed  the  patient  through  a  stomach-tube.  The  efforts  at  respiration 
became  more  painful,  and  at  times  I  thought  death  by  asphyxia  immi- 
nent. The  tongue  was  now  immovable,  lying  like  a  flabby,  reddened 
mass  in  the  mouth,  and  the  patient  lay  in  bed  entirely  helpless  through 
the  paralysis  of  his  limbs.  But  now  amendment  began,  and,  as  in  the 
case  just  cited,  with  the  gradual  disappearance  of  the  bulbar  symp- 
toms. Little  by  little  improvement  took  place.  Faradization  was 
now  brought  into  use,  and  was  employed  daily  to  the  tongue,  throat, 
and  extremities,  while  the  internal  medication  was  continued.  By  the 
fust  of  June  he  was  able  to  use  his  legs  in  standing,  and  his  arms 
and  hands  to  support  himself.  He  could  not  yet,  however,  employ 
them  in  feeding  himself.  About  the  first  of  July  he  could  walk  with 
1  eunc,  and  used  his  hands  well.  He  went  to  Saratoga  the  middle  of 
July,  and  while  thero  had  a   relapse,  consisting  in  a  Budden  paralysis 


476  DISEASES   OF   THE   SPINAL   CORD. 

of  the  left  lower  extremity,  by  which  he  was  again  deprived  of  the 
ability  to  walk.  He  was  there  attended  by  Urs.  Whiting  and  Lente, 
and  I  also  visited  him.  The  iodide  of  potassium,  which  had  been  dis- 
continued, was  resumed.  Under  its  use,  with  ergot,  hypodermic  injec- 
tions of  strychnia,  and  faradism,  he  has  again  acquired  the  power  of 
walking,  though  his  improvement,  owing  to  considerable  atrophy  of  the 
muscles  of  the  legs,  especially  the  gastrocnemii,  is  slow. 

It  may  be  mentioned,  incidentally,  that  after  he  began  to  lose  power 
in  his  legs,  he  fell,  upon  one  occasion,  and  struck  his  right  side  violently 
against  the  edge  of  a  wooden  bucket.  After  he  was  able  to  go  out,  I 
made  a  careful  examination,  and,  detecting  fluctuation  in  the  liver,  I 
removed  about  a  pint  of  pus  with  the  aspirator.  No  unpleasant  symp- 
toms followed,  and  there  was  no  reaccumulation  of  the  pus. 

The  treatment,  therefore,  which  in  my  opinion  is  best  adapted  to 
the  initial  or  advancing  stage  of  spinal  paralysis  in  the  adult,  is  that 
which  consists  in  the  persistent  use  of  the  iodide  of  potassium  and 
ergot,  both  given  in  large  doses.  The  former  I  carried,  in  both  of  the 
cases  cited,  to  half  an  ounce  daily,  and  the  latter  to  an  ounce.  Dr. 
Seguin '  reports  a  case,  as  occurring  in  the  practice  of  Dr.  T.  A. 
McBride,  and  which  he  saw  in  consultation,  in  which  the  fluid-extract 
of  ergot  was  given  in  like  quantity  daily,  and  in  which  recovery  ensued. 
This  treatment  is  based  upon  the  theory  that  the  first  stage  of  the  dis- 
ease in  question  is  characterized  by  a  congestion  limited  to  the  anterior 
tract  of  gray  matter. 

As  soon  as  the  muscles  show  the  slightest  sign  of  regaining  their 
power,  electricity  should  be  employed.  The  form  in  which  it  should  be 
used  depends  entirely  on  the  requirements  of  each  individual  case.  If 
the  faradaic  current  will  cause  contractions  in  the  paralyzed  muscles,  it 
is  the  preferable  form,  but  if  not,  then  the  interrupted  primary  or  gal- 
vanic current  must  be  applied  and  used  in  such  a  degree  of  intensity  a? 
will  cause  muscular  contractions. 

In  one  of  the  other  cases  of  the  four  which  I  have  treated,  while  the 
disease  was  advancing,  I  used  the  actual  cautery  to  the  spine — applied 
over  the  seat  of  the  disease,  as  near  as  could  be  determined  from  the 
extent  of  the  paralysis.  The  effect  was  apparently  excellent,  the  lesion 
ceasing  to  advance.  But  one  such  case  cannot  be  regarded  as  afford- 
ing more  than  an  indication.  From  what  I  have  seen,  however,  of  the 
power  of  the  actual  cautery  in  other  affections  of  the  cord,  I  should  be 
disposed  to  employ  it  in  future  like  cases  of  spinal  paralysis  of  adults. 
In  the  later  or  chronic  stage,  as  will  be  presently  shown,  it  is  certainly 
of  great  value. 

After  the  progress  of  the  disease  is  arrested,  the  treatment  which  is 
most  advisable  consists  in  the  persistent  use  of  electricity  to  the  para- 
lyzed muscles,  with  the  view  of  restoring  motility  and  preventing  or 
1  Op.  cit.,  p.  22,  Case  XXII. 


SPIXAL   PARALYSIS   OF   ADULT.-. 


477 


curing  atrophy  ;  the  hypodermic  injections  of  strychnia  in  gradually- 
increasing  doses,  till  the  physiological  effects  of  the  drug  are  pro- 
duced, when  the  doses  should  be  diminished,  and  again  increased, 
and  so  on  ;  and  repeated  applications  of  the  actual  cautery  to  the 
spine.  Three  or  four  applications  are  made  at  one  sitting  on  each 
aide  of  the  spinous  processes,  and  over  the  part  which  is  in  physio- 
logical  relation  with  the  paralyzed  regions. 

I  have  never  seen  a  case  of  spinal  paralysis  of  adults  which  was 
entirely  unamenable  to  this  treatment,  and  the  majority  recover  com- 
pletely.    In  the  accompanying  woodcut  (Fig.  46)  is  the  exact  appear- 


Fro.  46. 


ance  of  the  legs  of  a  woman  who  consulted  me  September  20,  1874, 
and  who  had  suffered  an  attack  of  the  disease  under  consideration 
some  three  years  previously.  As  will  be  seen,  the  calves  are  atrophied 
to  :m  extreme  degree,  and  her  walking  was  correspondingly  impaired. 
She  was  treated  with  the  galvanic  current  in  the  iirst  place,  and  subse- 
quently with  the  faradaic.  Strychnia  was  injected  into  the  limbs  daily, 
according  to  the  method  mentioned,  beginning  with  the  thirtieth  of  a 
grain,  and  the  act  ual  cautery  was  applied  to  the  lower  dorsal  and  upper 
lumbar  region  of  the  spine  six  times.   In  less  than  three  months  she  could 

walk  as  well  as  she  ever  did,  and  her  calves,  from  haying  measured  each 
only  eleven  and  a  half  inches  at  their  largest  circumference,  had  in- 
creased to  fifteen  inches  in  the  right,  and  fifteen  and  a  half  in  the  left. 

Electricity  bas  been  very  generally  employed  by  those  physicians 
who  have  recognized  the  disease  in  question.     Thus  Bernhardt1  re- 

1  M Ueber  elne  der  spinaleo  Eindcrlfthmnng  ahnliche  affection  Erwachsener,'1  Arth&v 
fur  Psychiatric  >/>n/  NervmkrankJuUen^  Band  iv.,  1 1  •  - 1  r  2,  1^7-,  p,  870. 


478  DISEASES   OF   THE   SPINAL   CORD. 

ports  a  case  of  recovery  mainly  through  its  agency,  as  do  also  Eisen- 
lohr,1  a  case  from  Friedreich's  clinic  ;  Frey,2  three  cases  from  Ktiss- 
maul's  clinic  in  Freiberg  ;  Seguin,'  several  cases,  in  which  electricitv 
was  a  part  of  the  treatment,  and  with  good  results  ;  Lincoln,4  com- 
plete recovery  after  marked  atrophy  ;  Leyden,6  a  bad  case  with  partial 
recovery,  so  as  to  be  able  to  walk  with  crutches  a  little  better  than  he 
could  before  treatment  ;  and  cases  mentioned  by  Duchenne.6 

In  my  own  practice,  I  have  treated  a  good  many  cases  with  elec- 
tricity alone — cases  in  which  the  paralysis  and  atrophy  were  limited, 
and  have  rarely  been  disappointed  in  the  results.  In  one  very  notable 
case,  sent  to  me  by  my  friend  Dr.  Christopher  Johnston,  of  Baltimore, 
the  gastrocnemius  was  rapidly  regenerated  through  the  agency  of  the 
interrupted  galvanic  current,  so  that  the  strength  could  be  measured 
daily  by  means  of  an  apparatus  devised  by  the  patient,  and  the  im- 
provement accurately  ascertained. 

With  the  electricity,  passive  movements  and  kneading  are  always 
useful,  and  the  patient  should  be  encouraged  to  use  the  affected  mus- 
cles up  to  the  point  of  fatigue,  at  repeated  times  during  the  day. 

2.  Inflammation  of  the  Motor  Cells. 

Thus  far,  only  one  disease  of  this  class  has  been  differentiated,  and 
it  is  characterized  by  paralysis  of  the  parts  involved,  without  atrophy. 

a.    Glosso-Lahio-Laryngeal  Paralysis. 

The  first  explicit  account  of  this  very  remarkable  disease  is  that  of 
Duchenne,7  who,  in  consideration  of  the  tendency  of  the  morbid  pro- 
cess to  advance  unchecked,  and  of  the  parts  affected,  designated  it 
"progressive  muscular  paralysis  of  the  tongue,  the  veil  of  the  palate, 
and  the  lips."  The  consequences  of  this  condition,  as  pointed  out  by 
Duchenne,  are  difficulties  of  articulation  and  of  deglutition,  and  at  a 
late  period  of  the  disease  frequent  attacks  of  strangulation,  during 
one  of  which  the  patient  may  die  ;  or  death  may  result  either  from 
inanition  or  syncope. 

But,  although  Duchenne  was  the  first  to  give  a  systematic  descrip- 

1  "  Zur  Lchrc  von  der  acuten  spinalen  Paralysie,"  Archiv  fur  Psychiatric  u.  s.  w., 
Band  iv.,  1874,  p.  219. 

2"Ucber  temporare  Erwachsener,  die  der  temporarcn  Spinallahmung  der  Kinder 
analog  sind,  und  von  Myelitis  der  Vorderhorner  auszugehen  scheinen,"  Berliner  klinischc 
Wochcnschrift,  Nos.  1-3,  1874. 

3  Op.  cit.,  Cases  XIX.,  XX.,  XXII. 

4  "A  Case  of  Spinal  Paralysis  in  an  Adult,  resembling  the  so-called  Infantile  Pa- 
ralysis," Boston  Medical  and  Surgical  Journal,  March  25,  1875. 

6  "Klinik  der  Nervenkrankheiten,"  zwciter  Band,  Berlin,  1875,  p.  199. 

6  Op.  cit.,  p.  458. 

1  "  De  l'electrisation  localisee,"  etc.,  deuxieme  edition,  Paris,  1861,  p.  621. 


GLOSSO-LABIO-LARYXGEAL   PARALYSIS.  479 

tion  of  the  affection,  it  was  observed  by  Dr.  F.  W.  Robinson,  in  1825, 
who  thus  writes  to  Sir  Charles  Bell:  '  "In  consequence  of  your  impor- 
tant discoveries  relating  to  the  nerves,  I  am  particularly  desirous  to  have 
your  opinion  in  the  following  case:  The  invalid  is  an  unmarried  lady, 
nearly  seventy  years  of  age,  who  has  enjoyed  uninterrupted  good  health 
up  to  the  present  illness.  She  has  had  occasional  short  attacks  of  gouty 
rheumatism  in  both  feet  and  also  in  the  knees,  of  very  short  duration. 
From  the  first  of  her  complaining  up  to  the  present  moment,  she  has 
been  free  from  headache,  and  from  pain,  numbness,  or  debility  of  the 
limbs.  The  vision  and  hearing  are  natural,  the  appetite  good  ;  the 
bowels  regular,  and  the  sleep  natural.  In  short,  there  is  not  the  slightest 
deviation  from  sound  health  except  in  the  particulars  I  shall  relate. 

"  Some  few  months  ago  she  had  some  difficulty  in  using  the  tongue, 
and  in  expressing  particular  words.  This  difficulty  has  gradually  in- 
creased, and  now  she  cannot  protrude  the  tongue  or  even  move  it.  She 
has  lost  her  speech  altogether.  The  tongue  itself  is  soft  and  pulpy,  but 
it  retains  its  sense  of  taste  and  of  feeling.  The  deglutition  is  impaired, 
and  occasionally  she  is  distressed  with  a  sense  of  suffocation  in  attempt- 
ing to  swallow  food,  which  now  she  is  obliged  to  do  with  great  care. 
She  cannot  hack  up  any  thing  from  the  throat  nor  draw  any  thing  from 
the  posterior  nares  by  a  back  draught.  The  features  of  the  face  are 
quite  natural,  and  the  skin  retains  its  feeling.  The  saliva  occasionally 
flows  from  the  mouth." 

This  is  certainly  a  very  accurate  description  of  a  case  which,  although 
its  real  nature  was  not  recognized  at  the  time,  was  undoubtedly  an  in- 
stance of  the  disease  under  notice. 

Then  Trousseau  in  1811,  just  twenty  years  before  the  publication  of 
Duchenne's  account,  recognized  it  as  an  affection  he  had  not  previously 
seen,  and  wrote  a  memorandum  of  the  existing  phenomena.2  Trousseau 
named  the  disease  glosso-laryngeal  paralysis,  in  his  lecture  on  the  sub- 
ject, and  this  was  afterward  amplified  by  Duchenne  into  glosso-labio- 
laryngcal  paralysis.  Many  cases  have  been  subsequently  reported,  and 
descriptions  of  the  affection  given,  but  no  one  has  added  any  thing  to 
the  graphic  symptomatology  of  Duchenne. 

Fifteen  cases  of  the  disease  have  come  under  my  observation  during 
the  past  ten  years. 

Symptoms. — It  rarely  happens  that  patients  seek  medical  advice  for 
the  initial  symptoms  of  the  disease  under  notice.  We  are  therefore,  in 
general,  obliged  to  rely  on  their  accounts  of  the  order  and  progress  of 
the  symptoms.  In  one  instance  only — and  this  patient  is  still  undei 
treatment — have  I  had  the  opportunity  of  observing  a  case  from  a  very 
early  point  in  the  course  of  the  disease. 

The  first  evidence  of  disease,  wITkIi  in  the  majority  of  instances  at- 

1  "  The  Nervous  System  of  the  Human  Body,"  London,  1830,  p.  cwii. 
'  "Lectures  on  Clinical  Medicine,"  Baare'a  translation,  p.  117. 


480  DISEASES   OF   THE   SPINAL   CORD. 

tracts  the  attention  of  the  pat;ent,  is  a  slight  difficulty  of  articulation, 
due  to  a  want  of  rapidity  and  exactness  in  the  movements  of  the  tongue. 
This  circumstance  occurred  in  eleven  of  my  cases.  In  the  others  the 
symptom  first  noticed  was  a  tendency  in  the  lips  to  remain  separate, 
and  the  consequent  necessity  of  using  some  degree  of  mental  action  to 
keep  them  closed.  In  a  short  time  the  restraint  in  the  motions  of  the 
tongue  becomes  more  distinctly  marked,  and  it  is  especially  character- 
ized by  an  inability  to  raise  the  extremity  to  the  roof  of  the  mouth,  or 
to  press  it  against  the  upper  teeth.  The  words,  therefore,  which  the 
patient  experiences  most  difficulty  in  pronouncing  distinctly  are  those 
which  begin  with  lingual  or  dental  consonants.  The  gutturals  he  can 
articulate  without  trouble  ;  and  the  labials,  except  when  the  affection 
begins  in  the  lips,  do  not  yet  give  him  inconvenience. 

The  next  symptom  to  make  its  appearance  is  difficulty  of  swallow- 
ing. The  food  is  not  promptly  grasped  by  the  constrictor  muscles  of 
the  pharnyx,  and  the  tongue  does  not  press  it  strongly  against  them. 
At  times  it  enters  the  pharynx,  and,  not  being  carried  onward  by  the 
muscles  of  deglutition,  may  slip  into  the  larynx  and  occasion  suffocation. 
Liquids  are  especially  difficult  to  swallow,  and  are  often  ejected  through 
the  nostrils. 

As  the  result  of  this  paralysis  of  the  muscles  of  deglutition,  the 
saliva,  instead  of  being  swallowed  as  fast  as  secreted,  accumulates  in 
the  mouth.  Here  it  becomes  stringy  from  its  mixture  with  the  buccal 
mucus,  and  when  the  patient  opens  his  lips  it  runs  out  in  streams. 
After  a  time  the  orbicularis  oris  becomes  so  far  paralyzed  that  the  lips 
cannot  be  kept  closed  without  continual  exertion,  and  then  the  viscid 
saliva  is  constantly  flowing  out  of  the  mouth.  In  four  of  the  cases 
mentioned  as  being  under  my  charge,  there  was  from  the  first  some 
flow  of  saliva  from  the  mouth,  not  apparently  from  any  difficulty  of 
swallowing,  but  from  the  existing  paralysis  of  the  orbicularis  oris  allow- 
ing the  mouth  to  be  almost  constantly  open.  The  other  muscles  sup- 
plied by  the  facial  nerve  in  the  lower  part  of  the  face,  singularly  enough, 
do  not  become  involved.  The  food,  it  is  true,  accumulates  between  the 
gums  and  the  cheeks,  and  has  to  be  removed  with  the  finger,  but  this  is 
not  due  to  any  paralysis  of  the  buccinator  muscles,  but  to  the  want  of 
power  in  the  tongue  to  move  the  alimentary  bolus  around  the  cavity  of 
the  mouth. 

When  the  disease  is  thus  fully  developed  by  the  paralysis  of  the 
tongue,  the  veil  of  the  palate,  and  the  lips,  the  patient  presents  a  pitia- 
ble spectacle.  He  is  unable  to  talk  ;  his  teeth  are  exposed,  from  the 
impossibility  of  closing  his  mouth  ;  the  saliva  either  runs  in  streams 
over  the  lower  lip,  or  he  goes  about  with  a  handkerchief  in  his  hand 
which  he  uses  to  absorb  the  perpetual  flow  ;  every  attempt  at  degluti- 
tion causes  him  the  utmost  distress,  and  puts  him  in  danger  of  his  life 
from  strangulation.     When  he  opens  his  mouth  the  glutinous  saliva  is 


GLOSSO-LABIO-LARYXGEAL   PARALYSIS. 


481 


Seen  hanging  in  viscid  strings  from  the  roof,  and  his  tongue,  which 
he  cannot  move,  lies  torpid,  like  an  inert  mass  of  muscles  as  it  is. 

The  facial  expression  is  well  seen  in  the  accompanying  woodcut 
(Fig.  47),  made  from  a  very  accurate  sketch  of  one  of  my  patients  suf- 


Fig.  47. 


'   \ 


fering  from  the  disease  in  question,  and  who  entered  my  consulting- 
room  with  his  handkerchief  to  his  mouth  to  absorb  the  streams  of  saliva 
which  were  ilowing. 

The  condition  of  the  patient  becomes  still  more  painful  from  the  im- 
plication of  the  respiratory  muscles.  The  walls  of  the  chest  become 
paralyzed,  and  be  is  unable  nol  only  to  breathe  deeply,  but  to  cough  so 
as  to  keep  the  bronchial  tubes  olearof  accumulations  of  mucus.  So 
feeble  is  the  respiratory  power,  thai  with  all  the  effort  lm  can  make  he 
■;i ii ii- >t  blow  out  a  candle. 

And,  besides  the  impossibility  of  articulation,  the  larynx  becomes 
paralyzed  .-it  ;i  later  period  of  the  disease,  and  phonation  becomes  im- 
possibl  .  The  patient  is  then  doomed  to  perpetual  silence,  even  the 
power  of  whispering  being  lost. 

A  remarkable  fact  is  characteristic  of  many  oases  of  glosso-labio- 
laryngeal  paralysis,  and  that  is  the  tendency  of  the  morbid  action  to 
extend  so  as  to  implicate  other  nerve-oella  lower  down  in  the  spinal 
:  -.' 


482  DISEASES  OF  THE   SPINAL  CORD. 

cord.  But  the  cells  thus  affected  are  not  motor,  but  trophic,  and 
as  a  consequence  the  resulting  condition  is  not  paralysis  but  mus- 
cular atrophy.  In  none  of  my  cases  was  there  muscular  atrophy 
in  any  part  of  the  body,  but  in  one,  to  be  presently  referred  to 
more  at  length,  there  was  incipient  paralysis  of  the  right  arm. 
The  ease  was,  therefore,  similar  to  the  one  reported  by  MM.  Du- 
chenne  and  Joffroy,  and  which  will  be  more  specifically  referred  to 
hereafter. 

The  reflex  excitability,  so  fully  developed  in  the  fauces,  gradually 
diminishes,  and  is  finally  lost  altogether. 

In  some  instances  atrophic  changes  unquestionably  occur.  In  such 
cases  bundles  of  muscular  fibres  here  and. there  in  the  tongue  undergo 
an  atrophic  degeneration,  which,  when  that  organ  is  protruded,  gives 
a  "  gouged  "  appearance  to  its  surface.  Electrical  reactions  of  degen- 
eration can  usually  be  obtained. 

Gradually,  as  the  disease  advances,  the  physical  powers  of  the  pa- 
tient yield.  He  becomes  unable  to  walk,  not  from  paralysis,  but  from 
general  debility,  due  to  insufficient  nutrition  and  imperfect  respiration. 
His  appetite  remains  good,  but  he  is  afraid  to  take  any  more  food  than 
is  barely  sufficient  to  sustain  life,  for  experience  has  taught  him  that 
suffering  and  danger  are  attendant  on  every  attempt  at  deglutition. 
At  last  he  ceases  to  make  the  effort,  and  is  fed  with  liquid  food  through 
a  stomach-tube.  The  saliva  during  sleep  runs  down  his  throat,  and  fits 
of  suffocation  are  the  result.  Too  weak  to  walk,  he  remains  in  bed, 
his  head  turned  to  one  side  so  as  to  allow  free  egress  for  the  saliva,  and 
he  dies  either  from  asphyxia,  from  the  cessation  of  the  action  of  the 
heart  through  the  continued  extension  of  the  lesion  to  the  cells  sup- 
plying the  pneumogastric  nerve,  or  from  some  intercurrent  affection. 

Generally  the  mind  remains  clear  to  the  last,  but  in  a  very  interest- 
ing instance  of  the  disease  occurring  in  an  officer  of  the  army,  sent  to 
me  by  my  friend  Dr.  Fleming,  of  Pittsburg,  this  was  not  the  case, 
manifest  dementia  making  its  appearance  toward  the  close.  The  emo- 
tions are,  however,  almost  invariably  easily  excited. 

The  first  case  of  this  disease  coming  under  my  observation  was  one 
referred  to  me,  over  eight  years  ago,  by  my  friend  Dr.  Edward  Bradley, 
of  this  city.  The  patient  was  a  watchmaker,  and  very  intelligent. 
Though  unable  to  speak  a  word,  I  obtained  a  good  deal  of  information 
from  him  relative  to  his  disease  by  asking  him  questions,  the  answers 
to  which  he  wrote.  The  accompanying  facsimile  of  one  of  his  writ- 
ten communications  to  me  (Fig.  48)  will,  I  doubt  not,  prove  of  interest. 
It  was  made  partially  in  answer  to  questions,  and  partially  at  his  own 
suggestion.  The  date  (March,  1847)  was  given  in  answer  to  my  ques- 
tion when  the  disease  appeared,  and  the  year  mentioned  is  a  mistake 
for  1867.  As  he  states,  there  was  a  little  trouble  with  his  right  arm. 
This  was  of  the  nature  of  paralysis,  there  being  no  muscular  atrophy 


GLOSSO-LABIO-LARYXGEAL   PARALYSIS. 


483 


484 


DISEASES   OF   THE   SPINAL   CORD. 


anywhere.     The  patient  died  about  six  months  after  I  saw  him,  the 
disease  lasting  a  little  over  a  year. 

Another  case — the  eighth — was  a  patient  in  the  New  York  State 
Hospital  for  Diseases  of  the  Nervous  System.  In  him  the  affection 
began  in  the  orbicularis  oris,  and  gradually  involved  the  tongue  and 
muscles  of  deglutition.  The  left  side  was  first  affected,  and  then,  a 
few  weeks  afterward,  the  paralysis  extended  to  the  right.  There  was 
nystagmus  of  both  eyes.  The  mind  was  perfectly  clear.  He  formed 
the  subject  of  a  clinical  lecture  on  glosso-labio-laryngeal  paralysis, 
which  I  delivered  during  the  session  of  1870-'71,  at  the  Bellevue  Hos- 
pital Medical  College.  The  case  is  further  remarkable  as  occurring  in 
an  exceptionally  young  person,  the  patient  being  but  thirty-two  years 
of  age.     Duchenne '  states  that  he  has  never  observed  it  in  persons 

Fig.  49. 


under  forty.  I  subjoin  a  representation  of  this  patient  (Fig.  49), 
taken  from  a  photograph.  The  paralysis  of  the  orbicularis  oris  is  evi- 
dent, although  it  is  partly  concealed  by  the  mustache.  At  the  time 
it  was  taken  the  patient  could  swallow,  but  was  conscious  of  a  diffi- 
culty in  beginning  the  act  of  deglutition. 

In  this  case  the  first  symptom  observed  by  the  patient  was  a  marked 

1  "  De  1' Electrisation  localised,"  Paris,  1S61,  p.  648. 


GLOSSO-LABIO-LARYXGEAL  PARALYSIS. 


485 


anaesthesia  of  the  face  and  lining  membrane  of  the  cheek  on  the  left 
side.  Krishaber '  has  since  reported  an  instance  of  like  character,  and 
regards  the  loss  of  sensibility  as  a  valuable  precursory  sign,  and  as  ex- 
hibiting in  a  very  striking  manner  the  physiognomy  of  the  disease. 

I   subjoin   the    engraving    (Fig.   50),   from    a   photograph,  repre- 
senting a  patient  who  came  from  the  West  to  consult  Dr.  Sayre  and 
myself.     He  entered   my  consult- 
ing-room   holding    his    handker-  FlG-  50- 
chief  to  his  mouth,  to  catch  the 
-i  reams  of  saliva  which  were  pour- 
Ing    from    it,    unable    to    speak   a 
word  and  scarcely  able  to  swallow. 

Causes. — The  etiology  of  glosso- 
labio-laryngeal  paralysis  is  very 
obscure.  Duchenne  attributes  one 
of  his  cases  to  mental  anxiety  ; 
two  cases  appeared  to  be  due  to 
syphilis  and  rheumatism.  In  no 
other  instance  could  he  assign  a 
cause. 

Of  my  own  cases,  one  was  ap- 
parently due  to  business  troubles 
resulting  from  petroleum  specula- 
tions ;  and,  in  one,  excessive  application  to  business  appeared  to  be 
the  cause.  In  one  other  case,  that  of  a  gentleman  of  this  city,  the 
disease  was  evidently  associated  with  syphilis;  and  in  one  it  was 
apparently  caused  by  a  blow  on  the  back  of  the  head,  and  in  one  by 
exposure  to  a  strong  draught  of  cold  air,  which  blew  directly  on  the 
nape  of  the  neck  and  occiput.  In  none  of  the  others  could  I  assign  any 
cause.  All  of  my  patients  were  between  the  ages  of  forty  and  sixty, 
except  the  one  whose  case  and  portrait  (Fig.  50)  have  been  given. 

Diagnosis. — Attention  to  the  account  of  the  symptoms  given  will 
prevent  any  mistake  in  diagnosis,  as  there  is  no  affection  which  re- 
sembles in  its  entirety  the  one  under  consideration.  In  the  very  early 
stage,  however,  it  may  be  confounded  with  simple  paralysis  of  the 
tongue  ;  or,  if  the  disease  begins  in  the  lips,  as  in  the  case  cited,  with 
facial  paralysis.  In  glossoplegia  there  are  other  symptoms  of  cere- 
bral disorder,  and  it!  facial  paralysis  the  loss  of  power  is  ii"t  confined 
to  the  lips. 

It  may  possibly,  in  some  cases,  nol  be  distinguished  from  the  gen- 
eral paralysis  of  the  insane,  which  generally  begins  with  paralysis  of 
the  tongue  and  weakness  of  the  lips.  The  facts  that  this  disease  is 
manifested  also  by  mental  Bymptoms,  and  thai  the  paralysis  gradual!) 

1  M  Anteatbe'sie  de  la  lensibilitd  rifles  dee  roiee  alriennea  el  di  >mme  prt 

ar  de  la  paralysis  labio-glasso-larvi  |      ■  //.  hebdomadairt,  November  29,  ls7'^ 


486  DISEASES   OF   TEE   SPINAL   CORD. 

involves  the  other  muscles  of  the  body,  will  suffice  for  making  an  exact 
diagnosis.  In  facial  diplegia  the  expression  of  countenance  is  very 
much  like  that  of  a  patient  suffering  from  glosso-labio-laryngeal  paraly- 
sis, but  here  the  resemblance  ends,  and  careful  examination  shows  even 
here  many  points  of  difference.  It  is  only  necessary  to  state  that  the 
tongue  is  not  paralyzed,  and  that  there  is  no  difficulty  of  swallowing  in 
double  facial  paralysis. 

In  progressive  muscular  atrophy,  attacking  the  tongue,  the  veil  of 
the  palate,  and  the  lips,  a  mistake  might  also  be  made.  But,  as  Du- 
chenne  remarks,  progressive  muscular  atrophy  rarely  begins  in  that 
way,  and,  when  it  does,  other  muscles  of  the  body,  especially  the  the- 
nar and  hypothenar  eminences,  will  soon  become  involved.  Charcot 
has,  however,  recently  reported  a  case,  to  be  presently  more  fully  quoted, 
in  which  progressive  muscular  atrophy  was  clearly  combined  with  glos- 
so-labio-laryngeal paralysis,  and  in  which,  on  post-mortem  examina- 
tion, though  the  volume  of  the  tongue  was  not  diminished,  the  muscu- 
lar fibre  had  undergone  degradation.  In  such  a  case,  of  course,  a 
complete  diagnosis  could  only  be  made  after  death.  In  ordinary  pro- 
gressive muscular  atrophy,  the  fact  that  the  atrophy  comes  on  before 
the  paralysis,  is  to  be  borne  in  mind. 

From  diphtheritic  paralysis  attacking  the  muscles  of  the  pharynx, 
glosso-labio-laryngeal  paralysis  is  readily  distinguished  by  inquiries 
relative  to  the  history  of  the  case,  and  by  the  fact  that  the  tongue  is 
not  involved  in  the  first-named  disorder. 

Prognosis. — There  is  no  instance  on  record  of  a  cure. 

All  my  patients  affected  with  the  disease  are  dead,  except  one 
whom  I  occasionally  see.  A  case  of  improvement  and  one  of  cure 
have  been  reported  by  Dr.  Cheadle,1  but  certainly  neither  was  an 
instance  of  glosso-labio-laryngeal  paralysis,  although  the  face,  the 
tongue,  and  muscles  of  deglutition,  may  have  been  paralyzed.  In  the 
first  of  these  the  disease  began  with  sudden  loss  of  speech,  then  retro- 
ceded,  then  returned.  There  was  facial  paralysis,  incontinence  of  urine, 
and  left  hemiplegia.  The  woodcut,  from  a  photograph,  of  this  case 
does  not  exhibit  a  single  feature  of  glosso-labio-laryngeal  paralysis. 
The  case  was  probably  one  of  syphilitic  basilar  meningitis,  and  the  pa- 
tient greatly  improved  "  under  iodide  of  potassium,  rest,  and  nutritious 
food,"  and  was  discharged  able  to  swallow  with  very  little  difficulty 
and  to  articulate  imperfectly,  indeed,  but  so  as  to  be  understood. 

In  the  second  case  a  complete  cure  was  effected,  and,  as  indicative 
of  the  character  of  the  disease,  I  subjoin  the  essential  parts  of  Dr. 
Cheadle's  report  : 

A  woman,  aged  forty-two,  entered  St.  Mary's  Hospital  in  Novem- 
ber, 1867.     Her  speech  was  so  much  affected  that  it  was  difficult  to 

1  " Labio-Glosso-Laryngeal  Paralysis,"  "St.  George's  Hospital  Reports,"  vol.  v.,  1871, 
p.  123. 


GLOSSO-LABIO-LARYXGEAL   PAEALYSIS.  487 

make  out  a  word  of  what  she  attempted  to  say  ;  but,  from  the  state- 
ment of  a  fellow-servant  who  accompanied  her,  and  her  own  subsequent 
statements,  the  following  history  was  elicited  :  For  some  months  she 
had  suffered  from  frequent  attacks  of  violent  shooting  pain  in  the  head, 
accompanied  by  dimness  of  vision,  and  quite  unlike  any  headache  she 
ever  felt  before.  With  this  exception,  she  had  remained  in  good  health 
till  a  few  days  before  she  applied  for  medical  aid,  when  she  was  sud- 
denly seized,  while  sitting  in  a  chair  in  the  daytime,  with  total  loss  of 
speech  and  paralysis  of  the  right  side.  Her  face  was  drawn,  the  right 
arm  and  leg  utterly  useless,  and  she  found  herself  only  able  to  utter 
inarticulate  sounds;  there  was  no  loss  of  consciousness,  or  it  was  so  tran- 
sitory as  to  escape  observation.  The  use  of  the  leg  was  fully  regained 
in  about  a  week  ;  but  the  arm  remained  weak  for  a  considerable  time. 
For  two  days  speech  was  so  far  abolished  that  she  could  only  utter 
inarticulate  sounds. 

When  fully  examined  several  weeks  after  the  attack,  it  was  found 
that  she  could  walk  perfectly  well,  but  that  the  arm  was  weak  and  sen- 
sation slightly  impaired.  Her  speech  was  thick,  indistinct,  and  nasal, 
and  she  was  not  able  to  protrude  the  tongue  fully.  The  condition  of 
the  lingual,  palatal,  and  facial  nerves  was  not  accurately  ascertained. 
She  complained  of  severe  shooting  pains  in  the  head,  and  of  extreme 
drowsiness. 

She  had  had  four  still-born  children  ;  and  an  eruption,  which  she 
said  was  very  much  like  small- pox,  made  its  appearance  shortly  after 
her  first  confinement. 

She  took  small  doses  of  iodide  of  potassium,  but  there  was  no  im- 
provement. Mercury  was  also  given,  without  good  result.  She  then 
came  to  the  hospital.  Articulation  was  still  very  indistinct;  she  spoke 
as  one  very  drunk,  and  was  quite  unintelligible.  In  reply  to  questions 
addressed  to  her,  she  had  uttered  meaningless  sounds. 

The  treatment  was  continued,  and  she  gradually  improved,  so  that  at 
last  she  spoke  with  perfect  fluency  and  clear  articulation. 

No  one,  who  has  ever  seen  and  studied  a  single  case  of  glosso-labio- 
laryngeal  paralysis,  could  mistake  this  case  of  Dr.  Cheadle's  for  one  of 
the  disease  described  by  Duchenne.  It  was  probably  a  case  of  syphi- 
litic cerebral  disease  like  the  first,  and  like  it  recovery  took  place  under 
anti-syphilitic  treatment.  Ameliorations  may  certainly  be  produced, 
but  probably  no  cure.  The  average  duration  of  the  disease  is  about 
tw<>  years 

Morbid  Anatomy  and  Pathology. — Previous  to  the  very  recent  re- 
searches which  have  given  us  a  clear  insight  into  the  morbid  anatomy 
of  glosso-labio-laryngeal  paralysis,  the  lesions,  detected  by  several  ob- 
servers, wero  atrophy  of  the  roots  of  the  hypoglossal,  faoial,  spinal 
accessory,    and   pneumogastric   nerves.      But   late   investigations  have 


488  DISEASES   OF   THE   SPINAL   CORD. 

shown  that  the  lesions  of  the  nerve-roots  are  secondary  to  others  more 
central  in  their  situation. 

It  has  already  been  shown,  in  this  chapter,  that  the  morbid  process 
in  certain  diseases  consists  of  atrophy  and  disappearance  of  nerve-cells 
forming  the  nuclei  of  origin  of  certain  nerves.  Very  minute  examina- 
tions, made  in  the  cases  of  persons  dying  of  the  disease  under  notice, 
show  very  clearly  that  it  also  consists  of  atrophy  and  disappearance  of 
nerve-cells. 

Thus,  in  the  case  cited  from  Charcot,1  the  tongue  had  preserved  its 
former  thickness  and  normal  dimensions,  but  the  patient  could  not  ar- 
ticulate, and  was  obliged  to  express  herself  by  signs.  Intelligence 
was  perfect.     There  was  some  atrophy  of -the  arms. 

The  post-mortem  examination  showed  that  the  extrinsic  muscles  of 
the  tongue,  and  those  of  the  supra-  and  sub-hyoidean  regions,  were  of 
normal  appearance  and  condition.  The  intrinsic  muscles  were  pale 
and  of  diminished  hardness. 

The  laryngeal  muscles  were  healthy,  except  the  posterior  crico- 
arytenoid and  crico-thyroideus,  and  presented  here  and  there  a  yellow 
coloration. 

The  muscles  of  the  pharynx  had  undergone  no  appreciable  altera- 
tion. The  muscular  coat  of  the  oesophagus  appeared  to  be  of  normal 
consistence  and  color. 

In  the  spinal  cord  the  alterations  were  confined  to  the  anterior 
horns  of  gray  matter,  and  to  the  proper  nerve-elements,  the  neuroglia 
being  healthy.  The  abnormal  condition  consisted  in  a  disappearance 
of  nerve-cells. 

In  the  bulbar  region  it  was  noticed  that  the  nucleus  of  the  hypo- 
glossal presented  very  pronounced  alterations,  which  here,  as  below, 
related  exclusively  to  the  nerve-cells.  The  neuroglia  was  intact.  Many 
of  the  cells  were  in  a  state  of  pigmentary  degeneration.  The  group 
of  cells,  considered  by  Lockhart  Clarke  to  be  the  inferior  nucleus  of 
the  facial,  were  smaller,  and  less  in  number  than  in  the  normal  state. 
The  other  cells  constituting  the  nucleus  of  the  facial  were  in  like  condi- 
tion. Similar  changes  were  observed  in  the  cells  in  relation  with  the 
filaments  of  origin  of  the  spinal  accessory  and  the  pneumogastric  nerves. 

In  the  case  which  Duchenne  a  has  made  the  basis  of  some  original 
views  on  the  subject  of  atrophy  of  nerve-cells,  and  to  which  reference 
has  already  been  made,  it  was  found  that  the  cells  constituting  the 
nuclei  of  origin  of  the  hypoglossal,  the  facial,  the  spinal  accessory,  and 
the  pneumogastric,  had  become — those  that  remained — affected  with 

1  "Note  sur  un  cas  de  paralysie  glosso-laryngee  suivi  d'autopsie,"  Archives  de physi- 
ologic, tome  ill.,  1870,  p.  247. 

a  "De  l'atrophie  aigue  et  chronique  des  cellules  nerveuses  de  la  moelle  et  du  bulbe 
rachidienne,  a  propos  d'un  observation  de  paralysie  glosso-labio-laryng6e,"  par  Du 
chenne  (de  Boulogne)  et  Joffroy,  Archives  de  physiologie,  No.  4,  1870. 


GLOSSO-LABIO-LARYNGEAL   PARALYSIS.  4,«9 

pigmentary  degeneration,  and  were  atrophied,  while  many  had  disap- 
peared altogether. 

Among  the  earliest  properly  conducted  examinations  of  the  medulla 
oblongata  is  that  made  by  Dr.  E.  R.  Hun,1  of  Albany,  in  a  case  which 
appears  to  have  been  a  typical  one  of  glosso-labio-laryngeal  paralysis. 
Sections  made  from  the  medulla  oblongata  showed  disappearance  of  the 
nerve-cells  and  hyperplasia  of  the  neuroglia  in  that  part  where  were 
situated  the  nuclei  of  origin  of  the  facial  and  hypoglossal  nerves.  The 
cells  that  remained  had,  in  many  cases,  lost  their  radiating  processes, 
and  were  in  a  state  of  pigmentary  degeneration. 

In  this  case  there  were  in  addition  symptoms  indicating  the  existence 
of  secondary  amyotrophic  lateral  spinal  sclerosis,  as  described  by  Bou- 
chard and  Charcot,  and  the  lateral  columns  of  the  cord  were  found  scle- 
rosed. 

It  may,  therefore,  be  considered  as  satisfactorily  determined  that 
the  essential  lesion  in  glosso-labio-laryngeal  paralysis  is  found  in  the 
medulla  oblongata  and  upper  part  of  the  spinal  cord,  and  that  it  con- 
sists of  atropine  and  disappearance  of  certain  nerve-cells  constituting 
the  nuclei  of  origin  of  the  hypoglossal,  the  facial,  the  spinal  accessory, 
and  the  pneumogastric  nerves. 

But  we  are  not  on  that  account  to  disregard  the  fact  that  phenomena 
similar  to  those  of  glosso-labio-laryngeal  paralysis  may  exist,  and  as  the 
result  of  very  different  lesions  of  the  medulla  oblongata,  or  even  of  no 
discernible  morbid  condition  of  that  organ.  Thus  in  a  case  reported 
by  Dumesnil a — in  which  there  was  paralysis  of  the  tongue,  the  lips,  and 
the  veil  of  the  palate,  together  with  atrophy  of  the  muscles  of  one  of 
the  upper  extremities — the  hypoglossal,  facial,  and  spinal  accessory 
nerves  were  found  atrophied.  No  thorough  microscopical  examination 
was  made  of  the  medulla  oblongata,  and  hence  such  lesions  as  those 
described  by  Charcot  and  Duchenne  were  not  detected.  But,  whether 
they  were  present  or  not,  it  is  undoubtedly  true  that  eccentric  lesions 
of  these  nerves  would  cause  paralysis  of  the  parts  involved  in  glosso- 
labio-laryngeal  paralysis. 

Trousseau  3  has  described  three  cases  in  which  post-mortem  examina- 
tions were  made.  In  one  of  these,  the  results  were  negative  from  in- 
completeness of  the  investigation  ;  in  the  second,  the  roots  of  the  hypo- 
glossal nerve  were  atrophied,  and  the  medulla  oblongata  was  harder 
than  was  normal  ;  and,  in  the  third,  the  roots  of  the  hypoglossal  and 
spinal  accessory  were  in  like  condition. 

In  all  of  these  cases  no  proper  microscopical  examination  was  made 
of  the  medulla  oblongata,  am!  consequently  we  are  without  information 
as  to  the  exact  condition  of  that  organ.      But  we  can  remark  of  these 

1 "  Labio-GloBBO-Laryngeal  Parol]  lis,'1  American  Journal  of  fiuonfty,  1871,  p.  194, 

''  QatetU  hebdomadalrt,  Join,  1859,  [>.  890. 

•  "  Lectures  on  Olinioal  Medicine,"  Bazire'a  translation,  I860,  p.  1 1 7.  tttta 


490  DISEASES   OF   TUE   SPINAL   CORD. 

cases,  as  of  Dumesnil's,  that  they  only  show  that  paralysis  may  be 
produced  by  lesions  of  the  nerves,  a  fact  which  required  no  further 
demonstration  than  it  had  already  received  many  centuries  ago.  It 
scarcely,  however,  admits  of  a  doubt  that  the  atrophy  of  the  nerves 
was  the  result  of  central  disease,  and  that  this  disease  was  situated  in 
the  medulla  oblongata. 

In  Dr.  Wilks's '  case,  the  roots  of  the  hypoglossal  and  spinal  acces- 
sory nerves  were  found  atrophied,  and  the  medulla  oblongata  was  evi- 
dently the  seat  of  serious  disease,  but  no  examination  as  to  the  cell- 
lesions  was  made,  nor  indeed  was  it  possible  then,  before  the  researches 
of  Lockhart  Clarke,  to  make  such  an  examination. 

Voisin  2  reports  the  case  of  a  patient  aged  seventy-seven,  who  en- 
tered the  Salpetriere,  and  who  soon  after  admission  suddenly  lost  her 
speech.  Gradually,  however,  she  reacquired  the  power,  though  she 
had  forgotten  some  words.  After  remaining  three  months  in  the  hos- 
pital, she  again,  after  a  violent  fit  of  excitement,  was  deprived  of 
speech,  and  also  lost  the  power  to  purse  up  the  lips  and  to  raise  the 
tongue.  The  mastication  and  deglutition  of  solid  substances  were 
impossible,  the  saliva  flowed  from  the  mouth,  the  uvula  was  immova- 
ble, the  inspiration  rattling,  and  the  respiration  generally  difficult.  Taste 
and  sight  extinguished.  The  glottis  was  unfortunately  not  examined. 
The  mind  was  unimpaired,  and  there  was  no  paralysis  of  the  limbs. 
The  patient  had  to  be  nourished  through  an  oesophageal  tube.  She- 
died  suddenly  after  the  last  attack. 

Now,  although  this  is  called  by  Voisin  a  case  of  glosso-pbaryngo- 
labial  paralysis,  a  title  which  he  uses  as  synonymous  with  glosso-labio- 
laryngeal  paralysis,  it  is  very  evidently  not  the  affection  originating  in 
the  nuclei  of  the  bulbar  nerves,  and  progressing  slowly  but  without  in- 
termission to  a  fatal  termination.  It  is  of  the  same  character  as  the 
cases  cited  from  Dr.  Cheadle,  and  would  not  be  referred  to  here  but  for 
the  fact  that  a  post-mortem  examination  was  made.  The  results  were 
as  follows  : 

There  was  a  small  yellow  focus  of  softening  at  the  external  part  of 
the  left  lenticular  ganglion,  which  extended  to  the  island  of  Reil.  To 
this  circumstance  the  reporter  attributes  the  amnesic  aphasia. 

At  the  upper  and  lower  surfaces  of  the  two  lesser  cerebral  hemi- 
spheres, just  beneath  the  connecting  arm  of  each,  were  discovered  two 
tumors  which  appeared  to  be  epithelioma  of  the  arachnoid.  The  left 
tumor,  of  the  size  of  a  walnut,  reached  to  the  medulla  oblongata,  in  such 
a  manner  that  the  auditory,  facial,  hypoglossal,  and  spinal  accessory 
and  glosso-pharyngeal  nerves  were  compressed.  These  nerves  were  by 
one-half  slenderer  than  those  of  the  right  side.     The  facial  was  soft- 

'-  "  Guv's  Hospital  Reports,"  vol.  xv.,  p.  1. 

*  Annates  medico-psychologiques,  January,  1871,  analyzed  in  the  Journal  of  Psycho- 
logical  Medicine,  New  York,  vol.  v.,  1871,  p.  816. 


GLOSSO-LABIO-LARYXGEAL   PARALYSIS.  491 

ened.  The  tumor  on  the  right  side  was  of  smaller  circumference,  and 
did  not  extend  to  the  medulla  oblongata. 

Neither  the  medulla  oblongata  nor  the  pons  was  sclerotic. 

No  microscopic  examination  of  the  medulla  was  made,  and  there- 
fore nothing  can  be  inferred  relative  to  the  state  of  the  nerve  nuclei. 

In  a  case  in  which  I  had  the  opportunity  of  making  a  post-mortem 
examination,  there  was  also  paralysis  of  the  tongue,  the  lips,  and  the 
pharynx,  but  the  associated  phenomena  were  not  such  as  to  warrant  the 
disease  being  designated  as  an  inflammation  of  the  anterior  tract  of 
gray  matter,  causing  glosso-labio-laryngeal  paralysis.  The  patient  was 
an  elderly  gentleman  of  this  city,  who  had  suffered  from  paralysis  of 
the  lower  extremities,  and  to  a  less  extent  of  the  arms,  for  several  years. 
This  condition  had  been  preceded  by  several  seizures  not  involving  loss 
of  consciousness,  but  mainly  characterized  by  deprivation  of  speech, 
irregular  respiration  and  circulation,  and  vomiting. 

When  I  first  saw  him  there  was  defective  articulation,  the  ton<me 
could  only  be  slightly  moved,  and  there  was  partial  paralysis  of  both 
sides  of  the  face.  The  function  of  deglutition  was  very  much  impaired. 
Solids  could  not  be  swallowed  at  all,  and  liquids  escaped  through  the 
nostrils.     The  saliva  ran  in  streams  from  the  mouth. 

But  the  most  marked  disturbance  was  in  the  respiration  and  the 
action  of  the  heart,  both  of  which  were  exceedingly  irregular,  the  latter 
intermitting  frequently,  and  generally  not  skipping  a  single  beat,  but 
two  or  three  at  once.     His  mind  was  unimpaired. 

I  predicted  his  death  in  a  few  days,  for,  from  the  history  of  the  case 
as  well  as  from  the  existing  phenomena,  I  was  convinced  that  the  nu- 
cleus of  the  pneumogastric  was  involved  with  that  of  the  hypoglossal, 
facial,  and  spinal  accessory  of  both  sides,  and  that  the  disease  was  ad- 
vancing. He  died  within  a  week,  and  a  post-mortem  examination  was 
allowed. 

The  brain  was  apparently  healthy  throughout,  except  that  the  pons 
Varolii  and  medulla  oblongata  were  in  a  state  of  extreme  softening. 
These  were  removed,  together  with  the  vertebral  arteries  as  far  down  as 
the  lower  border  of  the  anterior  pyramids,  and  with  the  basilar  and  its 
transverse  branches.  The  coats  of  the  basilar  were  thickened,  and  the 
lumen  of  the  vessels  almost  entirely  obliterated.  The  two  lower  trans- 
verse branches  on  either  side  were  entirely  closed  by  dense  fibrous  clots, 
presenting  all  the  appearance  of  thrombi.  The  left  vertebral  artery  was 
also  diseased  and  closed  by  an  old  clot  extending  about  an  inch  and  a 
quarter  from  its  junction  with  the  vertebral  of  the  opposite  side.  The 
tissue  of  the  pons  Varolii  and  medulla  oblongata  was  so  much  softened 
as  not  to  admit  of  hardening  in  chromic  acid.  The  parts  were  placed  in 
absolute  alcohol  and  examined  in  a  few  days,  but  the  degeneration  was 
so  thorough  that  nothing  more  could  be  ascertained  than  the  fact  of  the 
almost  complete  destruction  of  the  nerve-elements. 


492  DISEASES   OF   THE   SPINAL   CORD. 

In  this  case,  although  the  symptoms  were  in  some  respects  similar 
to  those  of  glosso-labio-laryngeal  paralysis,  yet  it  is  very  obvious  that 
the  affection  was  not  this  disease.  The  paralysis  of  the  extremities  and 
the  paroxysms  of  speechlessness  were  indicative  of  a  more  extensive 
and  different  lesion,  and  the  post-mortem  examination  showed  that  the 
original  trouble  was  altogether  extrinsic.  The  bulb  was  invaded  from 
the  exterior  instead  of  from  the  interior. 

It  would  be  just  as  proper  to  designate  the  case  described  on  page 
486,  under  the  head  of  spinal  paralysis  of  adults,  one  of  glosso-labio- 
laryngeal  paralysis  on  account  of  the  bulbar  symptoms,  as  to  consider 
the  one  just  described  and  others  of  its  class  as  coming  under  this  cate- 
gory. That  ischcemia  of  the  medulla  oblongata,  however,  will  give  rise 
to  the  symptoms  of  glosso-labio-laryngeal  paralysis  is  not  only  evident 
from  pathological  considerations,  but  also  from  recent  anatomical  re- 
searches. Thus  Duret '  concludes,  as  the  results  of  his  investigations, 
that,  when  a  clot  is  situated  in  one  of  the  vertebral  arteries,  it  interrupts 
the  circulation  in  the  anterior  spinal  artery,  and  consequently  in  the 
median  arteries  which  arise  from  it  ;  that  is  to  say  in  the  arteries  which 
supply  the  nuclei  of  the  spinal  accessory,  the  hypoglossal  and  the  infe- 
rior root  of  the  facial.  It  therefore  causes  the  development  of  the 
symptoms  of  glosso-labio-laryngeal  paralysis.  When  the  clot  occupies 
the  inferior  part  of  the  basilar  trunk,  it  cuts  off  the  blood  from  the  sub- 
protuberantial  branches  which  supply  the  nucleus  of  the  pneumogastric, 
and  sudden  or  at  least  rapid  death  is  the  consequence. 

In  regard  to  the  character  of  the  morbid  process  by  which  the  de- 
generation, atrophy,  and  disappearance  of  the  nerve-cells  are  effected, 
Leyden  8  considers  it  to  be  a  myelitis,  and  this  is  probably  the  correct 
view.  In  this  light,  therefore,  it  does  not  differ  essentially  from  the 
corresponding  process  which,  situated  lower  down  in  the  cord,  produces 
infantile  spinal  paralysis  and  the  spinal  paralysis  of  adults. 

Wachsmuth,3  who  was  among  the  first  to  study  the  subject,  argued, 
from  a  consideration  of  the  symptoms,  that  the  affection  in  question 
was  characterized  by  destruction  of  the  nerve-cells  in  the  floor  of  the 
fourth  ventricle,  and  that  the  degeneration  of  the  nerve-roots  was  a 
secondary  process.  As  we  have  seen,  it  was  reserved  for  Charcot  and 
Duchenne  and  Joffroy  to  establish  the  correctness  of  this  opinion  by 
post-mortem  investigations. 

As  to  the  acute  glosso-labio-laryngeal  paralysis,  or  acute  bulbar  pa- 
ralysis, as  it  has  been  called  by  Leyden  4  and  other  German  writers, 

1  "  Sur  la  distribution  des  arteres  nouricieres  du  bulbe  racbidien,"  Archives  de  physio- 
togie,  1873,  p.  9V. 

2  "  Ueber  progressive  Bulbiirparalyse,"  Archiv  fur  Psychialrie  tind  Nervenh-ankhei 
(en,  B.  ii.  und  iii.,  1870-'73. 

3  "Ueber  progressive  Bulbarparalvse  und  diplegia  facialis,"  Dorpat,  1861. 
«  "  Klinik  dcr  Neryenkrankheiten,"  Berlin,  1875,  B.  ii.,  p.  157. 


GLOSSO-LABIO-LARYXGEAL   PARALYSIS.  495 

and  the  "  glosso-labio-laryngeal  paralysis  of  apoplectic  form  "  of  Jof- 
froy  '  and  of  Proust,2  cases  such  as  those  described  by  these  authors, 
are  to  be  considered  in  the  light  of  the  foregoing  remarks,  and  not  as 
instances  of  inflammation  of  the  anterior  tract  of  gray  matter  leading 
to  destruction  of  the  motor  cells. 

In  regard  to  the  coexistence  of  glosso-labio-laryngeal  paraly- 
sis with  certain  affections  of  the  cord,  characterized  by  atrophy 
of  the  muscles,  the  point  will  be  fully  considered  under  the  heads 
of  Progressive  Muscular  Atrophy  and  Amyotrophic  Lateral  Spinal 
Sclerosis. 

One  other  point :  "What  is  the  essential  physiological  character 
of  the  cells  which  have  become  degenerated,  atrophied,  and  many 
of  which  have  disappeared!  In  infantile  spinal  paralysis,  and  in  the 
spina!  paralysis  of  adults,  we  have  seen  reason  to  think  that  the  cells 
which  are  the  seat  of  disease  are  both  motor  and  trophic,  for  these 
affections  are  evidenced  by  paralysis  and  atrophy.  But  in  the  disease 
under  consideration  there  is  seldom  atrophy,  which,  when  it  does  occur, 
is  to  my  mind  an  evidence  of  a  complication  of  glosso-labio-laryngeal  pa- 
ralysis with  progressive  muscular  atrophy — a  disease  to  be  considered 
subsequently — and  not  merely  to  an  extension  of  the  morbid  process 
from  the  nerve  nuclei  to  the  nerves  themselves,  which  is  the  view  gen- 
erally held  by  neurologists  ;  for  glosso-labio-laryngeal  paralysis  is  not 
a  disease  in  which  the  muscles  are  defectively  nourished,  but  one  the 
essential  feature  of  which  is  paralysis.  It  is  reasonable,  therefore,  to 
suppose,  with  Duchenne,  that  the  nerve-cells  which  have  become  dis- 
eased are  motor  cells. 

Onimus'  asserts  that  there  is  no  evidence  to  show  that  glosso-labio- 
laryngeal  paralysis  ever  exists  without  atrophy  of  the  tongue,  but  this 
is  < lirectly  at  variance  with  the  experience  of  other  observers  and  alto- 
gether inconsistent  with  my  own  investigations.  That  there  is  a  form 
of  progressive  atrophy  affecting  the  tongue  is  very  certain,  but  it  is 
not  glosso-labio-laryngeal  paralysis.  As  regards  the  relation  of  the 
symptoms  observed  to  the  known  distribution  and  functions  of  the 
nerves  concerned,  there  is  no  difficulty.  The  affection  of  the  hypo- 
glossal causes  the  paralysis  of  the  tongue,  and  the  consequent  impos- 
sibility of  articulation,  and  of  moving  the  food  in  the  mouth  ;  the 
implication  of  the  facial  accounts  for  the  paralysis  of  the  lips  and  the 
muscles  of  the  veil  of  the  palate,  and  the  resultant  impossibility  of 
sounding  certain  letters,  and  of  swallowing  ;   the  extension  to  the  spinal 

accessory  explains  the  paralysis  of  the  larynx,  the  loss  of  phonation, 

and  the  feebleness  of  respiration  ;   and  death,  when  it  takes  place  as  it 

1  MSar  mi  cm-  de  paralysie  [abio-gloBso-laryng<5e  a  forme  apoplectique  d'origine  bul- 
baire,"  Gazette  Medicate,  1872,  No.  LI. 

-  ir  la  paralysie  labio-gloaao-laryiige'e,"  Gazette  dee  ffdpitavx,  1870. 

3  "  Paraly.-ic  laljio-glosso-laryu;  ■  I        '  '•  dea  HdpUcna^  September  80,  1872. 


494  DISEASES   OF   THE   SPINAL   CORD. 

sometimes  does  from  the  sudden  stoppage  of  the  heart's  action,  is  due 
to  the  implication  of  the  pneumogastric,  to  which  cause  other  paralyses 
of  the  muscles  of  animal  life  are  to  be  ascribed. 

Treatment. — From  what  was  said  relative  to  the  prognosis,  it  will 
have  been  perceived  that  there  is  not  much  to  expect  from  treatment. 
I  have,  however,  occasionally  produced  good  results  which  have,  for  a 
time  at  least,  rendered  the  condition  of  the  patient  more  tolerable.  Thus, 
the  first  patient  who  came  under  my  care  was  much  relieved  by  fara- 
dization of  the  paralyzed  muscles.  He  improved  very  much  in  his  ability 
to  swallow,  and  in  power  over  his  tongue  and  lips.  These  ameliorations 
were  not  permanent.  In  the  case  of  the  gentleman  from  Pittsburg,  as 
well  as  in  all  the  other  cases  but  one,  similar  treatment,  together  with  the 
use  of  the  primary  galvanic  current  and  phosphorus,  was  without  the  least 
effect.  In  this  latter  case  some  benefit  was  apparently  produced  for  a 
time.  The  course  of  the  disease  was  certainly  less  rapid  than  before 
treatment  was  begun,  but  it  nevertheless  slowly  advanced  to  a  fatal 
termination. 

3.  Inflammation  of  the  Trophic  Cells. 

In  admitting  the  existence  of  trophic  cells  in  the  anterior  tract  of 
gray  matter  of  the  spinal  cord,  I  have  been  influenced  by  what  I  con- 
sider to  be  the  weight  of  evidence.  The  fact  is  one  which,  in  the  pres- 
ent state  of  our  knowledge,  is  not  capable  of  absolute  demonstration; 
but  the  subject  is  of  such  a  character  as  scarcely  to  require  proof  of 
that  nature.  The  inference  for  their  existence  is  as  strong  as  that 
which  we  draw  relative  to  the  presence  in  the  spinal  cord  of  cells  spe- 
cially in  relation  with  the  functions  of  motion  and  of  sensation.  As  we 
have  seen,  there  are  affections  of  the  cord  in  which  there  are  both  pa- 
ralysis and  atrophy.  In  such  cases,  we  have  good  reason  for  concluding 
that  the  cells  which  are  in  nervous  connection  with  the  paralyzed  and 
atrophied  muscles  have  both  motor  and  nutrient  properties.  This  de- 
duction is  strengthened  by  the  fact  that  there  is  another  disease  which 
is  characterized  by  the  existence  of  paralysis  without  atrophy,  and 
which  post-mortem  examination  shows  to  be  due  to  the  degeneration, 
under  the  influence  of  inflammation,  of  certain  cells  situated  in  the  me- 
dulla oblongata  and  in  direct  anatomical  relation  with  the  nerves  sup- 
plying the  paralyzed  parts.  These  cells,  there  is  every  reason  to  believe, 
are  exclusively  motor. 

We  have  now  to  consider  the  affections  of  the  spinal  cord,  and  still 
of  the  anterior  tract  of  gray  matter,  which  are  manifested  by  atrophy 
without  paralysis,  except  in  so  far  as  an  atrophied  muscle  necessarily 
possesses  less  power  than  one  which  is  of  full  size. 

Two  such  affections  have  been  recognized,  or,  rather,  one — progres- 
sive muscular  atrophy — has  been  regarded  as  a  disease  of  the  anterior 


PROGRESSIVE    MUSCULAR  ATROPHY.  495 

tract  of  gray  matter  of  the  spinal  cord  by  the  great  weight  of  author- 
ity ;  while  the  other — facial  atrophy — is  now  for  the  first  time,  so  far 
as  I  am  aware,  placed  in  the  same  category.  That  this  is  warranted 
by  the  clinical  histories  of  the  cases  I  shall  have  to  adduce,  will,  I 
think,  be  apparent  to  the  reader, 

a.  Progressive  Muscular  Atrophy. 

Although  cases  of  progressive  muscular  atrophy  were  noticed  by 
the  older  writers,  the  first  systematic  account  of  the  disease  was  given 
by  Duchenne,1  in  1849.  In  1850  M.  Aran2  published  his  memoir,  in 
which  he  gives  the  histories  of  eleven  cases;  and  three  years  subse- 
quently Cruveilhier3  read  a  paper  on  the  same  subject  before  the 
Academie  de  Medecine.  About  the  same  time  other  memoirs  were 
published  on  the  subject. 

But,  although  Cruveilhier  was  not  the  first  to  write  upon  the  affec- 
tion in  question,  he  was  the  first  to  describe  it,  and  Duchenne  and  Aran 
were  aware  that  he  had  done  so  in  his  lectures  for  several  years.  The 
disease  is  therefore  sometimes  called  Cruveilhier's  atrophy. 

Symptoms. — The  first  symptom  observed  in  the  majority  of  cases  is 
loss  of  strength  and  dexterity  in  certain  muscles  of  the  body.  If  these 
are  in  the  lower  extremities,  the  patient  finds  that  he  tires  in  walking 
sooner  than  he  used  to  do.  If  in  the  upper  extremities,  he  experiences 
weakness  in  the  shoulder,  arm,  or  hand,  according  to  the  muscles  af- 
fected. 

Soon  afteiward  pains  simulating  those  of  neuralgia  are  felt  in  the 
paretic  muscles.  These  are  not  probably  due  to  the  central  lesion,  but 
are  the  result  of  muscular  fatigue  which  is  itself  due  to  the  incipient 
atrophy  which  even  at  this  stage  exists. 

In  the  majority  of  cases — according  to  my  experience  in  all — fibril- 
lary contractions  are  perceived.  Thus,  of  fifty-two  cases  of  progressive 
muscular  atrophy  which  have  been  under  my  charge  during  the  past 
ten  years,  these  contractions  formed  a  prominent  feature  in  every  one. 
They  consist  of  slight  twitchings  of  separate  bundles  of  muscular  fibres, 
and  give  the  sensation  of  something  alive  being  under  the  skin.  They 
can  often  be  seen,  especially  when  superficial  fibres  are  involved,  and 
they  are  generally  the  avant  courrlcrs  indicating  the  extension  of  the 
disorder.  Even  if  for  a  time  they  are  not  noticed  they  can  always  be 
excited  by  a  smart  tap  on  the  atrophied  muscle,  except  in  the  latter 
stages  of  t h«'  disease. 

1  "Atrophic  muaculaire  aveo  transformation  grai  Slemoires  de l'academie  dea 

■dances,"  18  19. 

8  "Reoherchea  Bur  one  maladie  non  encore  decrite  du  Byeteme  muaculaire,"  A  rehires 
Generale  dr  Midecme%  1850. 

8  "Bur  la  paralyaie  muaculaire  progressive  atropbique,"  Archives  Gten&rdU  >/■  AACmmu, 
1868. 


496 


DISEASES   OF   THE   SPINAL   CORD. 


The  loss  of  strength  attracts  the  attention  of  the  patient  to  his 
limbs,  and  then  he  finds  that  the  weakness  is  accompanied  by  atrophy. 
If,  as  is  usually  the  case,  the  disease  begins  in  one  of  the  upper  ex- 
tremities, the  thenar  and  hypothenar  eminences  very  commonly  give 
the  first  evidence  of  atrophy.  The  ball  of  the  thumb  disappears,  and 
the  muscles  filling  the  space  between  the  first  and  second  metacarpal 
bones — the  adductor  pollicis  and  the  first  interosseous — likewise  shrink 
away.  The  whole  outline  of  the  metacarpal  bone  of  the  thumb  can 
thus,  very  soon,  easily  be  made  out. 

The  ball  of  the  thumb  is  often  the  starting-point  of  the  disease, 
and,  when  this  is  not  the  case,  it  generally  becomes  involved  at  some 
time  or  other  in  the  course  of  the  affection.  Of  the  fifty-two  cases 
occurring  in  my  experience,  the  disease  appeared  first  in  the  ball  of 
the  thumb  in  nineteen,  and  eventually  attacked  this  part  in  twenty- 
one  others.  The  upper  extremities  were  the  original  seat  of  the  dis- 
ease in  forty-two  cases,  the  trunk  in  four,  and  the  lower  extremities 
in-six.  Whether  the  affection  begins  in  an  upper  or  lower  extremity, 
the  tendency  is  for  the  opposite  member  to  be  next  involved. 

The  physiognomy  of  progressive  muscular  atrophy  is  very  striking, 
particularly  when  the  face  or  the  hand  is  its  seat.     One  very  well- 
marked    case  of   the   former   has 
FlG-  51-  come  under  my  observation,  and 

it  can  readily  be  understood  that 
the  change  effected  by  the  dis- 
appearance of  the  facial  muscles 
must  be  very  evident.  In  the 
case  in  question — represented  in 
Fig.  51) — the  right  side  of  the 
face  was  strikingly  involved,  and 
the  muscles  of  the  neck  and 
shoulder  on  the  same  side  were 
affected  to  a  marked  degree.  In 
W^j  the  hand,  the  atrophy  of  the  mus- 

cles which  give  this  member  its 
plumpness,  and  enable  it  to  per- 
form    the     complex     movements 
of  which  the  fingers  are  capable, 
causes  appearances  which  are  easily  recognizable.     By  the  disappear- 
ance of  the  thenar  eminence,  the  skin  over  it  hangs  in  loose  folds,  the 
thumb  falls  by  its  own  weight,  and  cannot  be  brought  into  apposition 
with  the  index-finger — the  palm  of  the  hand  is  hollowed  out,  and  the 
metacarpal  bones  can  be  distinctly  seen  and  felt. 

In  the  forearm,  the  situation  of  the  disease  can  be  readily  ascer- 
tained by  the  flattening  produced  by  the  disappearance  of  the  affected 
muscles,  and  in  the  arm  and  shoulder  the  effects  of  the  disease  are  still 


PROGRESSIVE   MUSCULAR   ATROPHY.  497 

more  evident.  In  three  cases,  the  disease  had  begun  in  the  right  del- 
toid, and  had  not  extended  beyond  this  muscle  when  the  patients  came 
under  my  charge.  In  all,  the  shoulder  was  flattened,  and  the  head  of 
the  humerus  and  the  acromion  process  could  be  distinctly  seen.  In 
another  case  it  was  limited  to  the  trapezius  and  scapular  muscles  of 
both  sides. 

In  the  lower  extremity,  the  changes  in  the  foot  are  not  so  remark- 
able as  the  corresponding  ones  in  the  hand,  but  the  effects  produced  by 
the  atrophy  of  the  peroneal  muscles,  the  tibialis  anticus,  and  those 
forming  the  calf  of  the  leg,  are  very  striking.  In  the  one  case,  the 
foot  drops,  and  the  patient  is  obliged  to  bend  the  knee  to  a  greater  ex- 
tent than  usual  in  order  to  make  the  toes  clear  the  ground  ;  in  the 
other,  the  heel  cannot  be  raised,  and  the  ankle  gives  way  with  the 
weight  of  the  body.  When  the  muscles  on  the  anterior  face  of  the  leg 
are  in  process  of  destruction,  the  forms  of  the  tibia  and  fibula  can  be 
distinguished,  and  the  space  between  the  two  bones  is  unfilled.  The 
disappearance  of  the  calf  makes  the  posterior  aspect  of  the  leg 
flat. 

In  the  thighs  the  atrophy  is  also  readily  perceived,  and  modifies  very 
materially  the  gait  of  the  patient.  When  the  extensors  on  the  anterior 
face  of  the  thigh  are  involved,  the  leg  cannot  be  thrown  forward;  when 
the  flexors  are  the  seat,  the  leg  cannot  be  raised,  and  the  whole  mem- 
ber has  to  be  lifted  up  by  the  action  of  the  flexors  of  the  thigh  on  the 
pelvis. 

A  singular  circumstance  connected  with  the  disease  is  the  tendency 
exhibited  for  a  single  muscle  or  a  group  of  muscles  to  escape  atrophy, 
while  all  the  surrounding  ones  are  profoundly  affected.  Thus,  as  in  a 
case  reported  by  Duchenne,1  all  the  muscles  of  the  hand  and  forearm 
were  completely  atrophied  with  the  exception  of  the  supinator  longus, 
which  remained  in  its  normal  condition.  This  is  well  shown  in  the  cut 
(Fig.  52)  from  Duchenne's  work. 

Sometimes  the  atrophy,  after  destroying  a  muscle  or  two,  ceases  to 
extend.  Thus,  in  a  case  referred  to  me  by  Dr.  D.  H.  Goodwillie,  of  this 
city,  the  atrophic  process  had  been  spontaneously  arrested  after  com- 
pletely destroying  the  muscles  of  the  right  thenar  eminence,  and  the 
patient  had  remained  for  eighteen  years  entirely  free  from  any  active 
manifestations  of  the  disease. 

The  temperature  of  the  atrophied  muscles  is  usually  several  degrees 
below  the  normal  standard.  In  the  case  of  a  gentleman  whom  I  recent- 
ly examined  with  reference  to  this  point,  and  whose  right  hand,  fore- 
arm, and  arm,  are  in  a  state  of  advanced  atrophy,  I  found,  by  means  of 
Dr.  Lombard's  instrument,  the  temperature  of  that  extremity  to  be  5° 
Fahr.  below  that  of  the  other. 

1  "De  rclcctrisatiou  localise,"  troisidme  edition,  Paris,  ls7"2,  p.  COG. 

33 


498 


DISEASES   OF   THE   SPINAL   CORD. 


Fio.  52. 


The  cutaneous  capillaries  are  usually  relaxed,  and  hence  the  skin 
over  the  affected  parts  is  discolored  by  the  passive  engorgement. 

The  electric  contractility  of  the  affected  muscles  diminishes  both 
to  the  faradaic  and  the  galvanic  currents  in  direct  ratio  to  the  atrophy 
of  muscular  substance.  As  the  muscle  gradually  decreases  in  volume, 
so  the  contractions  to  both  forms  of  current  perceptibly  fail.  When 
the  atrophy  becomes  extreme  the  faradaic  excitability  is  lost  alto- 
gether, but  so  long  as  any  muscular  fibres  re- 
main, slight  contractions  can  be  obtained 
from  the  galvanic  current.  The  polar  reac- 
tions, in  the  great  majority  of  cases,  remain 
unchanged,  but  .in  a  few  instances  the  anodal 
closure  contraction  has  been  found  to  be 
equal  to,  or  slightly  in  excess  of,  the  cathodal 
closure  contraction.  This  is  only  observed 
in  advanced  stages  of  the  disease. 

The  reflex  excitability  in  the  early  stages 
appears*  to  be  increased,  but  as  the  disease 
advances  it  becomes  less  and  less,  and  is 
finally  altogether  lost.  Thus,  when  the  fibril- 
lary contractions,  which  characterize  the  in- 
itial period,  are  temporarily  absent,  they  can 
be  readily  reexcited,  as  previously  mentioned, 
by  striking  the  skin  over  the  affected  muscle. 
Besides  the  paralysis,  which  it  must  be 
clearly  understood  results  from  the  atrophy, 
and  is  directly  proportional  to  its  extent, 
there  may  be  contractions.  These,  when 
present,  are  due  to  the  fact  that  the  atrophy 
has  not  attacked  all  the  muscles  of  an  ex- 
tremity simultaneously,  or  to  a  like  degree, 
and  consequently,  the  normal  antagonism  be- 
ing destroyed,  distortions  take  place.  When 
these  occur  in  the  hand,  they  produce  the 
main  en  griffe  of  Duchenne.  Of  the  twenty- 
nine  cases  occurring  in  my  experience,  seven 
only  had  any  distortions.  In  infantile  pa- 
ralysis, which  is  similar  in  several  respects 
to  progressive  muscular  atrophy,  contractions  and  distortions  are  much 
more  common. 

The  pupils  are  sometimes  contracted  from  the  implication  of  nerve- 
cells  in  the  cilio-spinal  region  of  the  cord.  This  was  the  case  in  one  or 
both  eyes  in  four  of  my  cases. 

The  course  of  the  affection  is  slow,  but  in  the  great  majority  of  cases 
it  advances  to  a  fatal  termination.    Death  takes  place  from  the  muscles 


PROGRESSIVE   MUSCULAR   ATROPHY. 


499 


of  respiration  becoming  involved,  from  exhaustion,  or  from  some  inter- 
current affection.     Several  of  my  cases  have  lasted  over  ten  years. 

It  is  worthy  of  notice  that  there  is  no  instance  on  record  of  the 
muscles  of  the  eye-ball  or  the  levator  palpebrse  superioris  being  affected. 

The  accompanying  woodcut  (Fig.  53),  from  Friedreich,  represents 
a  patient,  Ludwig  Bessing,  forty-five  years  old,  who  certainly  presents 


Fin.  53. 


a  remarkable  example  of  the  disease.  Almost  all  the  muscles  of  t  in- 
body,  trunk,  ami  extremities  were  in  a  state  of  extreme  atrophy,  the 
only  exceptions  being  found  in  the  loft  forearm.  The  disease  had  re- 
mained stationary  for  many  years,  during  all  of  which  period  there 
were  strong  fibrillary  contractions.  No  hereditary  influence  could  be 
ascertained  to  exist. 


500  DISEASES  OF  THE  SPINAL  CORD. 

MM.  Duchenne  and  Joffroy '  have  shown  that  glosso-lahio-laryngeal 
paralysis  is  sometimes  complicated  with  progressive  muscular  atrophy, 
and  that  this  latter  affection,  implicating  the  muscles  of  the  tongue, 
the  lips,  and  the  veil  of  the  palate,  has  hitherto  been  confounded  with 
the  first-named  disease.  It  differs  from  it,  however,  in  the  essential 
fact,  which  is  applicable  to  the  disorder  appearing  in  other  parts  of 
the  body,  that  the  loss  of  power  is  not  the  initial  symptom,  but  results 
directly  from  the  diminution  in  the  size  of  the  muscles.  This  point 
will  be  further  considered  under  the  head  of  Diagnosis,  when  other 
cases  similar  to  that  here  referred  to  will  be  brought  forward. 

The  progressive  muscular  atrophy  of  infants  presents  some  features 
different  from  those  met  with  in  adults.  Duchenne,2  who  has  elucidated 
this  point  of  the  subject,  has  ascertained  that  the  initial  atrophy,  in- 
stead of  beginning  in  the  upper  extremities,  as  it  usually  does,  or  in  the 
trunk  or  lower  extremities,  as  is  occasionally  the  case,  starts  from  cer- 
tain muscles  of  the  face,  giving  a  peculiar  expression  to  the  countenance. 
I  have  never  witnessed,  to  recognize  it,  a  case  of  progressive  muscular 
atrophy  in  an  individual  under  the  age  of  eight  years ;  consequently, 
no  instance  of  the  infantile  form  of  the  disease  has  come  under  my 
notice.  Duchenne  has  witnessed  fifteen  cases,  and  in  each  the  begin- 
ning of  the  malady  occurred  between  the  ages  of  five  and  seven. 

The  muscle  first  to  be  affected  is  the  orbicularis  oris,  and,  as  he 
states,  its  failure  to  contract  occasions  a  characteristic  thickness  of  the 
lips.  The  expansion  of  the  mouth,  as  in  laughing,  is  then  only  effect- 
ed by  the  buccinator  and  the  risorius.  Eventually,  other  muscles  of 
the  face  become  involved,  and  finally  the  atrophy  extends  to  the  supe- 
rior extremities,  the  trunk,  and  the  lower  limbs. 

The  accompanying  cut  (Fig.  54),  after  Duchenne,  represents  in  pro- 
file the  face  of  a  boy  thirteen  years  of  age,  whose  lips  had,  in  infan- 
cy, become  thick  and  pendent,  and  whose  orbicularis  oris,  levatores 
labii  superioris,  levatores  labii  superioris  alseque  nasi,  and  the  zygo- 
matici,  had  become  atrophied,  and,  when  stimulated  by  strong  faradaic 
currents,  gave  no  response.  At  the  age  of  twelve  the  muscles  of  the 
chest  had  become  affected.  In  this  case,  as  in  one  other  in  Duchenne's 
experience,  the  disease  had  been  transmitted  through  the  mother,  who 
was  herself  the  subject  of  progressive  muscular  atrophy. 

Charcot  and  Marie  3  have  described  another  form  of  progressive 
muscular  atrophy  in  which  the  morbid  process  is  first  observed  in 
the  muscles  of  the  foot.  This  form  of  the  disease  has  been  termed  by 
Tooth  the  "  peroneal  type."  The  atrophy  may  begin  either  in  the 
extensor  hallucis  longus,  the  common  extensor  of  the  toes,  or  in  one  of 
the  peronei,  and  from  them  extend  so  as  to  involve  the  gastrocnemius 

1  "  De  l'atrophie  aigue  et  chronique  des  cellules  nerveuses  de  la  moelle  et  de  bulbe 
racbidien,"  Archives  de  Physiologie,  No.  4,  1870,  p.  499. 

2  Op.  eit,  p.  518.  3  Rev.  de  Mid.,  Paris,  1886. 


PROGRESSIVE   MUSCULAR  ATROPHY. 


501 


and  later  on  the  muscles  of  the  thigh.  After  several  years  the  dis- 
ease appears  in  the  upper  extremities  and  then  runs  the  usual  course. 
There  are  fibrillary  contractions,  and  the  muscles  respond  feebly  but 
accurately  to  both  faradaic  and  galvanic  currents,  except  in  a  few- 
instances  in  which  degenerative 
reactions  are  observed. 

I  do  not  see  the  advisability 
of  creating  new  types  of  pro- 
gressive muscular  atrophy  and 
naming  them  in  accordance  with 
that  part  of  the  body  where 
the  disease  is  first  manifested. 
Whether  the  atrophy  begins  in 
the  hand,  the  face,  or  the  foot, 
it  follows  a  regular  and  definite 
course,  which  is  nearly  identical 
in  each  instance  and  undoubted- 
ly originates  from  a  lesion  of 
the  spinal  cord — to  be  referred 
to  later — which,  according  to  its 
situation  in  the  cerebro-spinal 
system,  may  produce  the  initial 
atrophy  in  one  part  of  the  body 
or  another. 

Causes. — Progressive  muscular  atrophy  is  not  a  disease  of  old  age. 
Only  two  of  my  cases  were  in  persons  over  fifty  ;  four  were  between 
forty  and  fifty,  and  forty-six  were  under  forty.  Of  these  latter,  three 
were  between  fifteen  and  twenty,  and  two  between  eight  and  ten.  The 
period  of  life  at  which  it  appears  to  be  most  common  is  that  extending 
from  twenty-five  to  thirty-five. 

Sex  is  a  strong  predisposing  cause.  All  of  my  cases  were  in  males, 
except  one,  a  lady  from  Providence,  Rhode  Island,  in  whom  the  face 
and  tongue  were  involved  in  the  morbid  process.  Roberts  '  states 
that,  of  ninety-nine  cases,  eighty-four  were  males,  and  only  fifteen 
females.  Other  authors  have  noted  the  greater  proclivity  of  males. 
The  difference  appears  to  be  due  to  the  greater  severity  of  muscular 
exertion  required  in  many  of  the  occupations  of  nun. 

Hereditary  influence  is  a  well-recognized  predisposing  cause.  Two 
of  my  cast's  sent  to  me  by  Dr.  Lincoln,  of  Washington  City,  were 
brothers,  two  others  are  sons  of  a  prominent  manufacturer  of  this  city, 
and  fourteen  others  had  relatives  affected  with  the  disease. 

Bui  by  far  the  most  remarkable  history  of  the  hereditary  transmis- 
sion of  the  disease,  which  has  come  to  my  personal  knowledge,  is  con- 
tained in  (he  following  account,  which  constitutes  a    pamphlet  writt*  n 
1  "An  Essaj  on  Wasting  Palsy,"  London,  1858,  p.  135. 


502  DISEASES   OF   TEE   SPINAL   CORD. 

by  one  of  the  unfortunate  subjects,  and  sent  to  me  by  Dr.  R.  F. 
Andrews,  of  Gardner,  Massachusetts.  The  interest  attaching  to  the 
whole  matter,  as  well  as  in  consideration  of  the  graphic,  though  homely, 
manner  in  which  the  story  is  told,  will,  I  am  sure,  be  sufficient  apology 
for  my  quoting  the  entire  pamphlet  : 

"muscular  atrophy. 

"  Among  my  ancestors  and  their  neighbors  this  disease  was  known  as  the 
'  Wetherbee  Ail ; '  definitely,  it  is  a  wasting  or  consumption  of  the  muscles. 
Until  recently,  it  has  been  considered  incurable  ;  the  cause  is  unknown,  but  gen- 
erally the  first  intimation  the  patient  has  of  it  is  a  shock.  My  opinion  is  that  its 
inception  is  some  time  previous,  but  not  noticed.  From  and  ever  after  the 
shock  its  progress  and  character  are  remarkable,  the  various  symptoms  and 
details  of  which  will  be  seen  in  the  individual  cases  I  shall  attempt  to  describe. 

"I  have  been  unable  to  trace  the  history  of  this  disease  beyond  my  great- 
grandfather, Ephraim  Wetherbee,  and  all  I  know  of  his  history  is  that  he  had 
six  sons  and  two  daughters,  and  that  he  died  of  the  'Wetherbee  Ail.'  His  son 
Asa  experienced  a  sensation  in  the  calf  of  both  legs,  as  if  struck  smartly  with  a 
whip  ;  I  do  not  know  how  long  he  lived,  but  he  failed  from  that  time ;  Isaac, 
another  son,  had  the  same  disease,  but  I  have  been  unable  to  learn  any  partic- 
ulars in  bis  case.  Two  others,  Calvin  and  Joseph,  the  latter  my  grandfather, 
died  in  South  America  of  diseases  prevalent  in  that  country ;  I  can  say  nothing 
of  the  others.  Hannah  Wetherbee,  one  of  the  daughters,  I  can  remember  to 
have  seen  walk  feebly  and  soon  after  confined  to  her  room  nearly  helpless,  and 
to  have  seen  her  coffin-lid  screwed  on.  Sarah  married  a  Mr.  Paine;  she  had  had 
seven  children  and  was  in  good  health  ;  she  was  walking  on  the  street  and  felt 
as  if  hit  in  the  calf  of  the  leg  by  a  stone,  and  turned  expecting  to  see  the  boy 
who  threw  it,  but  concluded  that  was  not  the  case ;  she  lost  the  spring  of  her 
toes,  as  she  expressed  it,  and  never  walked  naturally  afterward ;  she  told  her 
family,  on  her  arrival  home,  that  she  had  the  '  Wetherbee  Ail.'  She  lived  seven 
years,  had  the  best  of  care  and  medical  treatment;  she  had  two  children  during 
her  sickness,  the  last  a  son,  after  she  had  become  perfectly  helpless  and  only 
nine  months  previous  to  her  death.  She  had  nine  children ;  one  died  young,  the 
others  are  living  and  in  good  health.  I  had  these  particulars  from  the  eldest, 
Sarah  Paine,  who  married  Spaulding,  and  is  nearly  sixty  years  of  age,  has  gen- 
erally been  in  good  health,  excepting  during  some  three  years  she  suffered  from 
nervousness  and  lost  all  her  strength ;  but  she  recovered  and  for  some  twenty 
years  has  been  well.  She  had  a  son  and  daughter  who  both  married;  the 
daughter  died  of  consumption  of  the  blood,  the  son  is  in  good  health.  Mrs. 
Spaulding  names  other  cases  but  can  give  no  particulars  except  that  one  felt  the 
first  shock  in  the  foot  under  the  shoe-buckle,  such  as  were  worn  a  hundred  years 
ago ;  another  was  attacked  in  the  brain  and  lived  but  twenty-four  hours  (I 
should  not  call  that  a  case  of  muscular  atrophy) ;  another  requested  that  an 
examination  should  be  made  after  his  death,  which  being  done  showed  that  ali 
the  muscles  were  consumed. 

"Joseph  Wetherbee,  my  grandfather,  had  a  son  and  daughter;  the  daughter, 
Lucy,  married  a  Mr.  Pitts ;  she  had  only  a  son  and  daughter.  The  daughter 
lived  some  twenty  years  and  died  of  some  sudden  and  severe  sickness.  The  son, 
J.  Henry  Pitts,  is  still  living  and  is  about  forty-three  years  of  age:  has  suffered 


PROGRESSIVE   MUSCULAR  ATROPHY.  503 

much  from  rheumatic  fever.  Aunt  Lucy  herself,  enjoyed  good  health  till  about 
fifty  years  old,  when  she  died.  She  believed  there  was  nothing  peculiar  in  the 
so-called  '  Wetherbee  Ail.'  Her  last  sickness  was  of  an  entirely  different  char- 
acter. 

"  I  now  come  to  the  case  of  my  father.  He  was  of  a  robust  build,  had  a 
strong  constitution  and  was  temperate,  drinking  no  spirits  since  my  remem- 
brance, probably  not  much  before ;  used  some  tobacco  at  times,  and  worked 
hard  at  different  trades,  as  shoemaking,  farming,  and  chair-making.  "When  about 
thirty-nine  he  remarked  that  be  was  growing  old  fast,  and  some  of  the  neighbors 
discovered  a  slight  limp  in  his  walk.  I  was  not  living  at  home  at  that  time,  and 
do  not  know  much  of  his  condition  in  the  early  stages  of  his  sickness.  He  first 
discovered  a  weakness  in  the  right  thumb,  being  unable  to  open  his  pocket-knife 
in  the  usual  way.  The  right  hand  and  arm  lost  strength  faster  than  the  left ; 
and,  contrarily,  the  left  leg  failed  the  fastest.  He  thought  the  direct  cause  of  his 
lameness  to  be  over-exertion  in  harvesting  a  crop  of  meadow-hay,  in  August  or 
September,  1844.  He  continued  to  labor  about  a  year.  The  progress  of  the 
disease  was  rapid;  he  suffered  somewhat  from  painful  muscular  contractions  or 
cramps,  otherwise  he  had  but  little  pain.  The  larger  muscles  of  the  arms  and 
legs  became  soft  and  flabby,  and  diminished  in  size.  In  November,  1845,  he  cut 
his  fingers  in  the  shop,  went  home  and  never  entered  the  shop  again.  He  got 
about  the  house  with  crutches  several  months,  comfortably.  During  the  follow- 
ing winter  he  had  rheumatic  fever.  In  the  summer  of  1846  he  became  nearly 
helpless.  Mother  and  myself  lifted  him  to  his  feet,  and  to  and  from  his  bed  and 
chair.  The  kidneys  were  also  affected,  and  the  lungs  were  very  weak.  So  he 
wasted  in  flesh  and  strength,  and  died  on  the  10th  of  October,  1846,  a  little  more 
than  two  years  after  the  hard  work  in  the  meadow. 

"  I  can  say  no  more  of  the  above  cases,  except  that  the  persons  were  native- 
born  Americans.  Mrs.  Spaulding  thinks  we  descended  from  the  English.  I  do 
not  learn  that  there  was  dissipation  in  any  branch  of  the  family.  There  are 
branches  of  the  family  in  which  nothing  of  the  kind  appears ;  there  is  nothing 
of  it  in  the  Wetherbees  in  Scotland.  Mrs.  Spaulding  thinks  the  disease  was  in 
the  family  previous  to  the  time  of  my  great-grandfather. 

u  I  was  born  on  July  23,  1831,  in  Westminster,  Massachusetts.  At  the  age 
of  five  I  was  thrown  from  a  wagon  and  got  a  scalp-mark  from  the  horseshoe. 
At  the  age  of  six  I  remember  an  aching  head  and  discharge  at  the  ear ;  at  seven 
or  eight  a  bad  cold,  with  soreness  of  chest,  a  cough  and  hot  gin-sling,  none  of 
which  were  in  the  least  agreeable.  When  eleven  I  was  badly  poisoned  with  ivy, 
although  before  that  I  had  handled  it  with  impunity ;  at  fourteen  another  cold 
and  affected  chest  and  lungs,  with  ulcers,  or  something  like,  in  the  head. 

"  From  this  time  to  the  age  of  twenty-one  I  had  some  sick-headache ;  got 
sick  three  times  from  trying  to  paint  outside  work,  got  poisoned  with  ivy  and 
dog-wood,  but  did  not  lose  many  meals  or  much  sleep.  I  worked  at  chair- 
making  and  had  no  lack  of  out-door  exercise.  As  I  have  spoken  of  shocks  be- 
ing felt  by  some  of  the  above-named  persons,  I  am  reminded  that  I  felt  one  on  a 
day  in  the  summer  that  I  was  sixteen  ;  I  felt  as  if  struck  with  a  piece  of  board 
on  the  left  shoulder,  head,  and  neck.  I  looked  around  for  the  cause  but  saw  no 
one;  I  was  not  hit  nor  hurt;  have  felt  something  similar  since,  but  as  nothing 
came  of  I  thought  no  more  about  it.  At  twenty-one  I  had  a  lame  stomach, 
partly  from  work  and  from  getting  a  blow  in  the  breast  Ono  plaster  set  thai 
all  ri^'ht,  and  I  have  had  nothing  of  it  since. 


504  DISEASES   OF   THE   SPINAL   CORD. 

"In  January,  1855,  I  had  lameness  in  the  right  wrist  and  hand,  attributing 
it  to  a  slight,  and  at  the  time  unnoticed,  sprain  by  rolling  logs.  I  had  much 
pain  and  trouble  during  threo  or  four  years  ;  many  times  I  could  scarcely  write, 
and  came  to  use  the  hammer  and  saw  with  the  left  hand.  It  is  useless  to  name 
the  various  modes  of  treatment,  as  time  only  seemed  effectual  in  restoring  the 
parts  to  nearly  their  natural  condition.  In  December,  1855,  I  hod  a  severe  cold, 
affected  lungs  and  head  ;  had  discharges  at  the  ear,  but  kept  the  house  for  a  few 
days  and  recovered.  Early  in  the  summer  of  1857  I  had  poor  appetite  and  no 
ambition,  headache,  and  slight  night-sweats.  I  gave  up  work  early  in  August, 
put  myself  under  a  doctor's  care,  improving  much  in  two  months,  and  before 
winter  gained  my  usual  health.  Early  in  the  spring  of  1858  I  had  palpitation 
of  the  heart,  caused  by  eating  new  maple-sugar ;  have  been  subject  to  it  ever 
since,  at  intervals  from  a  week  to  a  year  and  a  half,  always  brought  on  by  drink- 
ing water  or  ale,  or  eating  an  apple.  I  felt  somewhat  weak  during  their  con- 
tinuance, but  usually  kept  at  what  I  happened  to  be  doing,  though  they  lasted  from 
six  to  thirty-six  hours.  Two  or  three  years  following  I  had  two  sharp  stitches 
in  the  back,  by  lifting  a  slight  weight,  resulting  in  a  lame  back  for  a  season. 

"  In  August,  1862,  I  enlisted  in  the  army  and  soon  went  to  Virginia ;  had  but 
little  difficulty  in  getting  accustomed  to  camp-life  and  climate.  I  had  no  occasion 
to  answer  surgeon's  call  until  the  following  winter,  when  I  got  cold,  being  on 
guard  night  and  day  during  Burnside's  so-called  '  mud  march,'  resulting  in  pain 
in  the  bowels  and  diarrhoea,  but  that  all  wore  away  in  a  month  or  two.  During 
May,  1863,  while  in  camp  at  Washington,  I  took  a  cold  which  troubled  me  till 
after  the  battle  of  Gettysburg,  when  I  had  my  left  thigh  fractured  by  a  spent 
grape-shot.  The  fracture,  only  a  simple  diagonal,  was  never  set,  the  bone  unit- 
ing in  its  own  way  and  time,  consequently  the  left  leg  is  about  two  inches  short- 
er than  the  other,  and  crooked. 

"  In  1864  I  received  my  discharge.  I  walked  with  a  cane  the  following  sum- 
mer, then  gave  it  up  ;  experienced  no  difficulty  excepting  the  limp  resulting  from 
the  shortness  of  the  leg.  During  the  year  1865  I  was  engaged  in  work  which 
kept  me  on  my  feet.  I  frequently  walked  two  miles,  out  and  back,  but  experi- 
enced more  fatigue  than  in  previous  years.  In  May,  1866,  I  went  to  Chicago, 
and  engaged  in  sedentary  occupation  ;  had  about  seven-eighths  of  a  mile  to  walk 
to  and  from  work.  I  usually'walked  rapidly,  many  times  beating  the  horse-cars. 
In  July,  1867,  I  went  to  Pennsylvania  and  engaged  in  chair-making;  on  my  feet 
all  of  the  time,  and  some  of  the  time  standing  still  at  a  machine  ;  also  walked 
much  over  the  rough  hilly  road3  in  that  country.  I  was  there  upward  of  three 
years;  during  the  time  I  had  two  or  three  attacks  of  lame  back,  also  of  piles. 
When  taking  an  armful  of  stock  from  the  floor  I  found  it  convenient  to  keep  a 
stick  in  the  right  hand  to  assist  in  rising.  In  a  letter  to  my  brother  I  remarked 
I  felt  that  I  was  getting  old.  As  I  was  then  about  the  same  age  my  father  was 
when  he  made  the  same  remark,  the  coincidence  is  remarkable. 

"Late  in  1869  or  early  in  1870,  I  noticed  a  fibrillous  contraction  just  above 
the  right  knee,  about  half-way  from  the  anterior  to  the  inside.  It  is  a  tremu- 
lous twitching  of  the  muscles,  which  is  seen  in  the  muscles  of  slaughtered  ani 
mals  after  the  skin  is  taken  oft*.  It  is  painless  but  somewhat  disagreeable,  and 
more  noticeable  after  retiring.  In  two  or  three  days  it  was  gone.  I  was  at 
that  time  standing  at  a  lathe  during  the  day,  and  walking  rapidly  morning,  noon, 
and  night.  In  November,  1870,  I  came  to  Gardner,  where  my  employment  was 
such  that  I  had  to  stand  stiller  than  ever.     I  was  advised  to  sit  on  a  stool  part 


PROGRESSIVE   MUSCULAR  ATROPHY.  505 

of  the  time,  but  I  was  not  inclined  to  do  so.  I  walked  rapidly  to  and  from  the 
shop,  each  trip  requiring  about  twelve  minutes,  four  trips  a  day  up  hill  and 
down.  In  February,  1871,  I  felt  a  general  lameness  or  muscular  soreness  from 
over-exertion,  loss  of  sleep,  and  taking  cold.  I  had  had  such  experiences  before, 
most  persons  have  the  same.  About  the  20th  or  25th  of  March  I  noticed  for 
the  first  time  that  I  went  up-stairs  with  much  difficulty,  the  trouble  seeming  to 
be  in  the  right  thigh.  On  the  26th  of  March  I  walked  to  Westminster,  a 
distance  of  five  miles,  and  back.  I  felt  generally  fatigued,  but  noticed  no  par- 
ticular lameness.  That  was  the  last  foot-journey  of  any  distance  I  ever  took. 
Twice  in  April  I  quickened  my  pace  to  pass  some  persons  on  the  sidewalk,  and 
felt  a  quick,  painful  sensation  in  the  anterior  portion  of  the  right  thigh.  A  few 
days  subsequent  to  this  there  was  an  alarm  of  fire  about  twelve  o'clock.  I 
started  to  run,  but  gave  it  up  after  a  few  steps,  and  have  not  tried  to  run  since. 

"I  was  a  little  anxious  about  all  this,  but  did  not  suspect  any  permanent 
lameness  existed.  I  cannot  say  when  the  thought  of  the  '  "Wetherbee  Ail '  came 
into  my  mind.  On  May  11th,  as  I  was  going  of  an  errand  in  the  morning,  I 
stopped  to  throw  a  stone  at  a  small  hawk  in  an  apple-tree,  but  fell  myself,  and 
the  hawk  flew  away.  Twice  soon  after  I  fell  on  throwing  a  stone.  About  this 
time  I  had  severe  cramps  in  the  right  thigh,  and  have  the  impression  that  there 
were  cramps  in  the  right  thumb.  I  consulted  a  doctor  about  this  time,  and  be- 
gun a  regular  course  of  treatment.  The  1st  of  June  I  gave  up  going  home  for 
my  dinner,  and  sat  on  a  stool  much  of  the  time  while  at  work.  I  still  walked 
comfortably,  but  could  not  raise  my  weight  up  an  ordinary  step,  and  I  had  to 
be  careful  that  the  knee  set  at  every  step,  or  it  would  cripple  and  let  me  down. 
The  reader  will  notice  that  the  leg  which  was  not  broken  failed;  as  it  was  some 
two  inches  longer  than  the  other,  it  had  to  bear  the  greater  burden,  and,  in  go- 
ing up-hill  or  up-stairs,  virtually  had  to  raise  my  weight  two  inches  higher  at 
every  step  than  the  broken  leg.  The  tremulous  twitching  was  very  marked 
during  this  time,  and  occasional  painful  cramps.  I  continued  to  lose  strength 
all  summer,  and  was  obliged  to  give  up  some  kinds  of  work. 

"  September  1st,  I  found  that  the  right  thigh  measured  only  sixteen  inches, 
while  the  left  measured  nineteen.  I  used  a  cane  at  this  time  and  found  it  of 
much  service.  At  this  time  I  rode  to  and  from  the  shop.  About  the  1st  of 
November  I  found  the  left  leg  began  to  fail.  The  1st  of  January,  1872,  I  found 
much  difficulty  in  walking  only  a  short  distance.  I  gave  up  work  and  went  to 
the  Massachusetts  General  Eospital  for  five  weeks;  but  no  effect  of  the  treat- 
ment was  apparent;  think  the  right  thigh  had  decreased  to  fourteen  and  one- 
half  inches  in  one  year.  There  was  but  very  little  strengtli  in  the  right  leg,  the 
muscle  of  the  thigh  was  very  flabby,  and  the  heat  was  lower  than  in  the  other  leg. 
I  resumed  my  occupation  in  February.  The  fibrillous  contractions  and  painful 
cramps  had  by  this  time  nearly  ceased  in  the  right  leg,  but  were  visible  in  the 
left ;  also  noticed  weakness  in  the  right  thumb,  especially  when  cold,  and  could 
not  hold  a  carpenter's  pencil  in  the  usual  way.  I  cannot  state  the  number  of 
times  that  1  fell ;  I  continued  to  ride  to  my  work.  Late  in  May  I  could  bear  no 
freight  <>n  my  left  toes.  Meantime  1  had  bandaged  my  right  foot  and  leg  t>>  the 
knee,  on  account  of  swelling.  On  the  27th  of  July  I  was  thrown  from  a  car- 
riage, the  immediate  result  of  which  was  a  general  muscular  Boreness,  particu- 
larly in  the  left  foot  and  arm-;. 

"  From  this  time  the  progress  of  tho  disease  was  marked  and  rapid,  espe- 
cially in  the  ballot'  the  right  thumb  and  the  left  thigh.    1  now  found  it  unsafe  to 


506  DISEASES   OF   THE   SPINAL   CORD. 

Btep  without  a  cane,  or  out  of  the  reach  of  something  permanent.  As  the  cold 
weather  came  on,  I  had  to  change  my  job  for  a  lighter  one  in  a  warmer  place. 
I  gave  up  walking  in  the  shop,  used  a  wheel-chair,  and  was  during  the  fall  put 
into  a  buggy  by  a  strong  man.  I  continued  to  work  through  December,  except- 
ing some  of  the  coldest  days,  but  on  the  last  afternoon  of  the  year  1872  I  fell 
and  severely  sprained  the  left  knee ;  was  obliged  to  quit  work,  and  have  done 
nothing  since. 

"  At  no  time,  since  I  first  felt  the  lameness  in  the  right  thigh,  have  I  been 
able  to  say  with  truth  that  I  was  a  little  better,  or  even  about  the  same  ;  but 
that  I  was  not  so  strong  as  I  was  a  month  previous.  This  disease  never  stands 
still.  I  will  close  this  sketch  by  saying,  that  at  this  writing  I  cannot  stand 
alone,  have  no  control  of  the  right  leg  whatever,  and  cannot  move  the  toes. 
The  left  is  very  weak ;  both  feet,  and  the  legs  below  the  knee,  are  somewhat 
cold  most  of  the  time.  I  dress  without  assistance.  My  arms  are  not  strong 
enough  to  raise  my  weight  to  my  feet ;  have  not  strength  to  cough  or  sneeze 
with  any  force.  Have  a  fair  appetite  and  sleep  well.  It  is  probable  that  nearly 
every  muscle  in  the  system  is  affected,  as  I  have  felt  the  cramps  and  tremulous 
contractions  in  nearly  every  part.  There  is  no  loss  of  sensation  in  any  part. 
The  large  muscles  of  the  right  thumb  are  much  wasted,  the  whole  hand  has  a 
bony  appearance,  and  the  third  finger  droops.  Sometimes  I  cannot  pick  up  a 
pin,  and  my  writing  is  scarcely  legible.  I  gave  up  all  treatment  six  months 
ago,  as  I  could  never  see  any  difference  in  the  progress  of  the  disease  while 
under  treatment  and  while  not. 

"  One  theory  is,  that  this  disease  is  not  inherited  by  the  descendants  of  the 
females  ;  and  the  history  of  Mrs.  Paine's  family  seems  to  confirm  it.  My  object 
in  writing  this  is,  that  those  into  whose  hands  it  may  fall,  who  are  predisposed 
to  this  disease,  may  keep  a  watch  upon  themselves ;  and  I  exhort  them  to  mod- 
eration in  labor  and  physical  exertion,  and  in  all  things,  and  that  they  may  have 
a  history,  though  imperfect,  of  the  cases  which  have  appeared  in  our  family ; 
that  they  may  immediately,  on  suspicion  that  they  are  attacked  by  any  unusual 
thing,  apply  for  the  best  help  within  their  power.  I  waited  some  two  months  be- 
fore taking  any  measures  for  relief.  This  disease  is  also  known  as '  wasting  palsy.' 
It  is  known  in  other  families.  The  so-called  living  skeletons,  who  are  exhibited 
as  curiosities,  are  sufferers  from  muscular  atrophy  in  its  worst  form.  I  am  the 
oldest  of  five  ;  one  sister  and  three  brothers  still  enjoy  fair  health.  None  of  us 
have  used  tobacco  or  spirituous  liquors. 

"  E.  H.  "Wethekbee. 
Gardner,  Massachusetts,  March  81, 1873." 

In  relation  to  this  case,  Dr.  Andrews,  in  sending  me  the  pamphlet, 
writes,  under  date  of  March  30,  1874: 

"This  man,  Wetherbee,  died  December  23,  1873. 

"His  sister  has  recently  consulted  me  with  symptoms  of  the  same  disease. 
The  left  arm  and  shoulder  are  affected.  The  twitching  of  the  fibrillar  is  worse  at 
night.  I  prescribed  iron  and  quinine,  and  rest.  I  was  present  at  your  clinic  at 
Bellevue  two  years  ago  when  you  exhibited  a  patient — a  bridge-builder — from 
Ohio,  with  the  disease.' 

Two  members  of  this  family,  within  the  knowledge  of  the  writer  of 
the  pamphlet,  were  affected  with  progressive  muscular  atrophy,  and  it 


PROGRESSIVE   MUSCULAR   ATROPHY.  507 

is  probable  that  other  members,  as  he  was  informed,  before  his  great- 
grandfather, were  its  subjects.  An  interesting  circumstance  is,  that  two 
of  the  cases  were  females,  and  it  is  likewise  a  notable  fact  that  the 
children  of  one  of  these,  nine  in  number,  exhibited  no  symptoms  of  the 
disease.  We  have  seen  that  in  pseudo-hypertrophic  spinal  paralysis 
the  affection  is  only  transmitted  through  the  females,  while  progressive 
muscular  atrophy,  so  far  as  this  history  goes,  appears  to  be  only  im- 
mediately hereditary  through  the  males.  Atavism  was  therefore  mani- 
fested in  a  different  way  than  it  is  in  the  former  affection.  Duchenne, 
however,  as  we  have  seen,  has  witnessed  two  cases  occurring  in  children 
in  which  the  disease  was  transmitted  directly  through  the  mothers  who 
were  themselves  the  subjects  of  the  malady. 

But  nothing  on  this  point  can  surpass  the  instructive  histories  re- 
lated by  Dr.  Naunyn  *  relative  to  cases  brought  before  his  medical  clin- 
ic in  Konigsberg.  Six  generations  were  subject  to  the  disease.  Mem- 
bers of  three  generations  were  alive  at  the  time  Naunyn  delivered  his 
lecture,  and  the  clinical  histories  of  seven  cases  were  personally  known 
to  him.  The  oldest  of  these,  Dorothea  Braun  (n&e  Bessel),  was  seventy 
years  old.  Her  father  and  grandfather  had  the  affection,  to  her  knowl- 
edge, and  her  father  told  her  that  her  great-grandfather  was  also  its  sub- 
ject. Dorothea  had  eleven  brothers  and  sisters,  of  whom  only  one, 
Minna,  a  sister,  had  the  disease.  Of  her  own  seven  children  four  wer;: 
affected.  Of  Minna's  three,  one  dying  in  early  infancy,  two  were  dis 
eased.  Of  Dorothea's  uncles,  seven  in  number,  two  suffered  from  the 
malady. 

The  table  on  page  508  shows  at  a  glance  the  relationship  of  the 
several  members  of  this  remarkable  family,  and  the  channels  through 
which  the  disease  was  transmitted  directly,  and  by  atavism.  From  its 
examination  we  see — 

1.  None  of  the  sons  of  Daniel  Bessel  were  affected,  but  two  of  the 
daughters,  Dorothea  and  Minna,  were,  and  the  malady  was  propagated 
by  them. 

2.  Of  Minna's  three  children,  all  females,  two  had  the  disease. 

3.  Of  Dorothea's  seven  children,  two  boys  and  two  girls  were  af- 
fected, while  two  boys  and  one  girl  escaped. 

4.  One  of  the  boys,  Hermann,  and  one  of  the  girls,  Emilie,  who  es- 
caped, had  each  a  boy  who  had  the  disease,  thus  affording  two  examples 
of  atavism,  one  through  the  male  and  one  through  the  female. 

This  history  is  in  marked  contrast  to  that  of  Wetherbee  so  far  as 
the  line  of  descent  is  concerned,  and  the  two  together  may  be  con- 
sidered as  definitely  settling  affirmatively  the  question  of  the  heredi 
tary  transmission  of  progressive  muscular  atrophy. 

2  ''  Ueber  Hereditiit  dcr  progrossiwn  Minki'latrnphio,''  reported  by  Dr.  fidhortt  m 
Berliner  Idiniaehe  Wochenschxfl,  N09.  42  and  43,  1873. 


508 


DISEASES   OF   THE   SPINAL   CORD. 


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PROGRESSIVE   MUSCULAR  ATROPHY.  509 

From  some  facts  which  will  be  adduced  under  the  head  of  treatment 
there  is  reason  to  believe  that  syphilis  is  occasionally  a  cause  of  pro- 
gressive muscular  atrophy. 

The  exciting  cause  is  often  impossible  of  detection.  This  was  the 
case  in  twenty-nine  of  the  instances  that  have  come  under  my  observa- 
tion. Of  the  remaining  twenty-three,  injuries  of  the  spine  were  the 
cause  in  two,  exposure  to  cold  and  dampness  in  thirteen,  and  excessive 
muscular  exertion  in  eight.  Of  these  latter  cases,  two  occurred  in  the 
persons  of  ballet-dancers,  the  disease  making  its  appearance  first  in  both 
gastrocnemii  muscles  simultaneously  ;  one  in  a  gentleman  who  had 
overtasked  the  muscles  of  the  upper  extremities  by  severe  and  long- 
continued  exertion  in  rowing — the  muscles  about  the  shoulders  being 
affected;  in  two,  the  muscles  of  the  right  hand  were  first  attacked,  as 
the  result  of  excessive  use  of  the  pen  in  writing;  in  one,  it  was  induced 
by  the  occupation,  that  of  a  bricklayer,  requiring  the  patient  to  bear 
the  weight  of  his  body,  during  his  work,  mainly  on  one  leg — the  one 
attacked;  in  one,  it  was  apparently  induced  by  running  a  long  distance; 
in  one,  it  began  in  the  thenar  eminence  of  the  right  hand  of  a  bridge- 
builder;  in  one,  it  attacked  the  muscles  of  the  hand  and  forearm,  begin- 
ning in  the  ball  of  the  thumb  in  a  man  whose  occupation — faro-dealer — 
required  him  to  use  his  thumb  and  fore-finger  in  a  peculiar  way  for 
many  hours  at  a  time.  Venereal  excesses  have  been  alleged  as  a  cause, 
hut  I  have  seen  nothing  to  support  the  assertion. 

Diagnosis. — Progressive  muscular  atrophy  may  be  confounded  with 
infantile  spinal  paralysis,  spinal  paralysis  of  adults,  pseudo-hypertro- 
phic  paralysis,  amyotrophic  lateral  spinal  sclerosis,  and  various  second- 
ary forms  of  atrophy. 

From  all  these  diseases  it  is  discriminated  without  difficulty,  if  atten- 
tion be  paid  to  its  peculiar  features,  which  in  the  main  are  as  follows  : 

1.  The  absence  of  fever  and  of  pain  in  the  back. 

2.  The  gradual  progress  of  the  atrophy,  the  muscles  being  attacked 
one  by  one  and  not  en  masse,  as  in  the  other  diseases  named. 

3.  The  fact  that  there  is  not  paralysis  in  the  proper  sense  of  the 
word,  the  loss  of  power  being  simply  the  result  of  a  diminished  mass 
of  muscle. 

4.  The  retention  of  the  electric  contractility  so  long  as  there  are 
muscular  fibres  to  contract  and  the  absence  of  polar  degenerative 
reactions. 

5.  The  presence  of  fibrillary  contractions,  which  are  very  rarely 
met  with  in  other  atrophic  diseases,  except  amyotrophic  lateral  scle- 
rosis, the  diagnosis  from  which  will  be  herewith  pointed  out. 

Progressive  muscular  atrophy,  when  manifested  in  the  tongue,  has 
often  been  mistaken  f or  glosso-labio-laryngeal  paralysis.  It  is  readily 
distinguished,  however,  from  this  latter  disease  by  the  fact  thai  atrophy 
is  not  an  accompaniment  of  the  morbid  process  which  characterises 


510  DISEASES    OF   THE    SPINAL    CORD. 

glosso-labio  laryngeal  paralysis.  In  progressive  muscular  atrophy  at- 
tacking the  tongue  the  organ  is  marked  by  knots  and  depressions,  the 
latter  corresponding  to  the  situation  of  the  atrophied  muscular  bundles 
and  the  former  to  the  as  yet  untouched  portions.  In  glosso-labio  laryn- 
geal paralysis  the  tongue  lies  motionless  in  the  mouth,  undiminished  in 
size. 

In  locomotor  ataxia  there  is  sometimes  a  wasting  of  the  muscles, 
but  the  fact  that  the  atrophy  is  shown  in  masses  of  muscles  at  once,  and 
the  clinical  history  of  the  patient,  will  suffice  to  render  the  diagnosis 
exact. 

In  rheumatic  affections  there  is  often  atrophy,  but  this  is  consecu- 
tive on  paralysis,  and  in  the  cases  of  tumors  of  the  cord  we  have  the 
phenomena  of  slow  compression  in  addition  to  those  of  muscular  atro- 

In  cases  of  injury  of  the  cord  or  of  the  nerves  supplying  a  part,  pa- 
ralysis is  the  first  symptom  to  make  its  appearance,  though  atrophy  may 
very  quickly  follow.  In  such  instances  the  electric  contractility  is  soon 
lost.  Attention  to  the  clinical  history  of  such  cases  will  render  a  mis- 
take in  their  diagnosis  almost  out  of  the  question. 

Prognosis. — From  what  has  been  said,  it  will  readily  be  apprehended 
that  progressive  muscular  atrophy  is  a  very  serious  disease;  indeed,  it 
is  one  of  the  most  progressive  of  all  the  affections  to  which  the  term  has 
been  applied. 

In  only  three  cases  have  I  succeeded  in  arresting  the  course  of  the 
disease,  and  in  restoring  the  atrophied  muscles.  One  of  these  was  that 
of  a  highly-intelligent  gentleman,  formerly  an  officer  in  the  navy,  but 
now  a  resident  of  this  city,  whose  case  has  already  been  referred  to  as 
having  been  induced  by  rowing;  the  other  was  that  of  the  patient,  also 
previously  mentioned,  in  whom  the  affection  was  induced  by  cold,  and 
which  began  in  the  right  deltoid  muscle.  Both  of  these  patients  were 
entirely  cured,  regaining  full  muscular  power.  The  other  was  a  man 
who  came  to  my  clinic  at  the  University  Medical  College  during  the  win- 
ter of  1874-'75. 

In  four  other  cases,  which  I  saw  before  the  disease  had  advanced  to 
a  great  extent,  its  progress  was  arrested,  but  there  has  as  yet  been  no 
restoration  of  the  wasted  muscles;  in  two  of  these  there  was  no  prob- 
able cause  of  the  affection. 

The  coexistence  of  a  clinical  history  of  syphilis  probably  makes  the 
prognosis  more  favorable  than  would  otherwise  be  the  case. 

The  existence  of  an  hereditary  tendency  renders  the  prognosis  much 
more  grave;  and  the  fact  of  the  disease  having  lasted  a  long  time  is  also 
of  unfavorable  import. 

Morbid  Anatomy  and  Pathology. — Investigations  in  regard  to  the 
morbid  anatomy  of  progressive  muscular  atrophy  relate  to  the  condi' 
tion  of  the  spinal  cord,  the  nerves,  and  the  affected  muscles. 


PROGRESSIVE   MUSCULAR   ATROPHY.  511 

The  spinal  cord  has  been  examined  in  cases  of  progressive  muscular 
atrophy  by  Bergmann,  Meryon,  Gull,  Luys,  Lockhart  Clarke,  and 
others,  with  very  different  results;  some  of  these  observers  finding  no 
change  whatever,  and  others  detecting  notable  variations  from  the  nor- 
mal structure.  In  three  cases  examined  by  Clarke,1  disorganization  of 
the  spinal  cord,  especially  of  the  gray  matter,  was  found,  with,  in  one 
case,  deposit  of  amyloid  corpuscles. 

More  recently  Hayem,'J  and  Charcot  and  Joffroy,3  have  studied  the 
morbid  anatomy  of  progressive  muscular  atrophy  with  great  care.  In 
Hayem's  case,  the  disease  affected  the  muscles  of  the  upper  extremi- 
ties to  such  an  extent  as  to  render  them  powerless  from  the  shoulders 
down.  The  patient  died  from  paralysis  of  the  diaphragm,  and  of  pneu- 
monia. 

On  post-mortem  examination,  the  spinal  cord  appeared  healthy  to 
the  naked  eye.  The  anterior  roots  of  the  cervical  nerves  were,  how- 
ever, notably  atrophied.  The  most  attenuated  were  those  of  the  second, 
third,  fourth,  and  fifth  pairs.  The  sympathetic  was  healthy.  On  mi- 
croscopic examination  of  the  cord,  the  most  marked  characteristic  was 
atrophy  and  disappearance  of  the  nerve-cells.  In  some  portions  there 
were  none  to  be  seen,  but  there  were  large  numbers  of  free  nuclei, 
and  of  cells  containing  many  nuclei.  The  atrophy  of  the  nerve-cells, 
and  of  the  anterior  cornua  of  gray  substance,  was  greatest  at  the  level 
of  the  second  and  third  cervical  nerves,  and  extended  as  low  as  the  fifth 
cervical.  This  region  was  that  from  which  the  nerves  supplying  the 
atrophied  muscles  were  derived.  In  the  dorsal  and  lumbar  regions  there 
was  no  atrophy  of  nerve-cells  or  of  nerve-roots. 

A  consideration  of  this  case  shows,  as  Hayem  remarks,  that  it  is  one 
which,  during  life,  exhibited  the  usual  symptoms  of  progressive  muscu- 
lar atrophy,  and  that,  at  the  post-mortem  examination,  lesions  were 
found  in  the  muscles  in  the  anterior  roots  of  the  nerve,  and,  above  all, 
in  the  spinal  cord.  The  alterations  from  the  healthy  structure  of  the 
cord  consisted  of — 

1.  Abnormal  vascularization  with  dilatation,  and  sclerosis  ot  the  ar- 
terioles, and  of  the  larger  capillaries. 

2.  A  more  or  less  abundant  exudation  surrounding  the  blood-ves- 
sels. 

S.  Multiplication  of  the  elements  of  the  interstitial  tissue  (the  neu- 
roglia),  and  finally  atrophy,  and  disappearance  of  a  very  great  num- 
ber of  the  nerve-cells. 

1  Beale'e  "  Archive*  of  Medicine,"  vol.  III.,  1861 ;  also,  same,  vol.  iv.;  also,  Bntis/t  awl 
Fbreiffn  J/i  li<:o-Chirurgir<u  Reiiew,  vol.  xxx.,  1862. 

8  "  Note  sur  un  cas  d'atrophie  musculaire  progressive,  avec  16sions  de  la  moSlle,"  Ar 
thiva  it  I'lujsiologie,  No.  2,  1869,  p.  221,  and  No.  3,  1861,  p.  391. 

3  "Deux  cas  d'atrophie  musculaire  progressive,  avec  lesions  de  la  substance  grise  etdu 
faisccaux  ant6ro-lateraux  de  la  moollc  6pini6re,"  Archives  de.  Physiologie,  Nos.  3  and  b, 
1809. 


513  DISEASES   OF  THE   SPINAL   CORD. 

These  facts  point  to  the  existence  of  chronic  inflammation  of  the 
gray  substance  of  the  cord,  beginning  in  the  nerve  or  parenchymatous 
tissue,  and  subsequently  involving  the  neuroglia  or  interstitial  sub- 
stance. 

The  two  cases  of  MM.  Charcot  and  Joffroy  have  also  been  very  care- 
fully and  thoroughly  studied. 

The  chief  features  of  the  first  case  were,  progressive  muscular  atro- 
phy, especially  marked  in  the  superior  extremities;  atrophy  of  the 
muscles  of  the  tongue  and  of  the  orbicularis  oris,  and  paralysis  with 
rigidity  of  the  inferior  extremities.  The  patient  was  a  woman,  and,  be- 
coming suddenly  very  weak,  died  asphyxiated. 

At  the  autopsy,  the  anterior  roots,  especially  those  of  the  cervical 
region,  were  found  greatly  atrophied  and  discolored.  The  cord  ap- 
peared healthy  to  the  naked  eye,  except  that  at  the  dorso-lumbar  en- 
largement it  was  softened.  On  microscopical  examination,  however, 
the  nerve-tubes  of  the  anterior  columns  were  discovered  to  be  atrophied, 
a  great  number  being  only  represented  by  the  axis  cylinder,  while  the 
connective  tissue  was  very  much  increased.  The  posterior  columns 
were  not  involved  in  the  least. 

In  examining  the  gray  substance  of  the  cervical  region,  the  authors 
were  struck  with  the  extreme  degree  of  atrophy  which  the  cells  of  the 
anterior  cornua  had  undergone ;  a  large  proportion  of  them  had  entirely 
disappeared,  leaving  no  trace  behind  them.  The  posterior  cornua  ap- 
peared to  exhibit  all  the  qualities  of  the  normal  condition. 

The  alterations  in  the  other  regions  of  the  cord  were  not  directly 
connected  with  the  muscular  atrophy,  except  as  regards  the  medulla  ob- 
longata, where  the  cells  of  the  nuclei  of  origin  of  the  hypoglossal  were 
found  to  be  atrophied,  and  even  completely  destroyed.  In  the  second 
case,  similar  structural  changes  were  found.1 

As  Charcot  states,  when  the  alterations  of  the  neuroglia  are  very 
pronounced,  the  anterior  horn,  which  is  the  seat  of  the  morbid  process, 
may  be  considerably  reduced  in  size.  This  condition  is  well  shown  in 
the  accompanying  woodcut  (Fig.  55),  which  represents  a  section  of  the 
spinal  cord  taken  from  the  cervical  region  of  a  patient  who  had  been 
the  subject  of  progressive  muscular  atrophy — a,  the  left  anterior  horn 
of  gray  matter;  b,  the  right  anterior  horn,  the  cells  of  which  are  atro- 
phied with  the  exception  of  a  small  group  at  c.  The  whole  right  ante- 
rior horn  is  seen  to  be  diminished  in  size. 

1  These  cases,  which  at  the  time  were  considered  to  be  instances  of  progressive  mus- 
cular atrophy  with  complications,  are  now  to  be  classed  under  the  head  of  amyotrophic 
lateral  spinal  sclerosis.  I  have  described  here  the  morbid  anatomy  exhibited  by  them  in 
bo  far  as  it  relates  to  the  lesion  of  the  cells  in  the  anterior  horns  of  gray  matter,  reserv- 
ing  the  consideration  of  the  other  lesions  for  a  subsequent  division  of  the  subject.  It 
may  he  said  now,  in  anticipation  of  a  fuller  discussion,  that  the  alterations  of  the  gray 
matter  of  the  anterior  uorns  appear  to  be  the  same  in  the  two  diseases. 


PROGRESSIVE  MUSCULAR  ATROPHY. 


513 


MM.  Prevost  and  David1  have  recently  reported  a  case  of  atrophy 
of  the  thenar  eminence,  similar  to  that  related  on  page  482  as  occur- 
ring in  my  own  experience.  They  had  the  opportunity,  however,  of 
making  a  post-mortem  examination,  the  patient  dying  of  a  wound  of 
the  head.  The  man,  the  subject  of  the  disease,  had  had  from  his  in- 
fancy complete  atrophy  of  the  muscles  of  the  ball  of  the  right  thumb. 
Even  the  bone  was  atrophied.     There  had  never  been  pain. 

Fig.  65. 


On  post-mortem  examination  there  were  found:  manifest  atrophy 
of  the  anterior  root  of  the  right  eighth  cervical  nerve;  slight  atrophy 
of  the  anterior  root  of  the  right  seventh  cervical  nerve,  and  atrophy 
of  the  right  anterior  horn  of  gray  matter  in  relation  with  these  roots. 
The  muscles  of  the  thenar  eminence  were  entirely  destroyed  ;  but  all 
the  other  muscles  of  the  hand  and  arm  were  normal. 

In  this  case  the  relation  between  the  spinal  lesions  and  the  affected 
muscles  was  sufficiently  explicit. 

Still  more  lately  MM.  Pierret  and  Troisier3  have  examined  the  spinal 
oordfl  of  two  patients  who  died  of  progressive  muscular  atrophy,  and 
have  confirmed  in  all  essential  respects  the  results  obtained  by  the 
observers  previously  mentioned.  The  character  of  the  lesions  of  the 
oord  and  nerves  may  therefore  be  considered  as  definitely  ascertained; 
and   it    is  equally  an   established    fact,  first  noticed  by  Gruveilhier,  that 

'"  Note  but  un  oas  d'atrophie  des  muscles  de  l'eminence  thenar  droite  avec  lesions 
ile  Is  mo&Ue  epiniere,"  Archivmdi  Fhysiologit,  1*71,  p 

*  "  Note  snr  deux  oas  d'atrophie  museulaire  progressive,"  Archive*  de  Physiologic 
1875,  p.  237. 

34 


514  DISEASES   OF   THE   SPINAL   CORD. 

the  anterior  roots  of  the  spinal  nerves  derived  from  the  affected  por- 
tion of  the  cord  and  supplying  the  diseased  muscles  are  generally 
found  atrophied  from  the  disappearance  of  a  certain  number  of 
nerve-tubes.  This  is  a  secondary  lesion  resulting  from  the  spinal  de- 
generation. 

The  atrophy  of  the  muscles  is  due  to  the  degeneration  and  ulti- 
mate disappearance  of  the  fibrillar.  To  the  naked  eye  they  appear 
pale  and  attenuated.  By  microscopical  examination,  it  is  seen  that 
the  transverse  striae  of  the  fibrillae  are  in  course  of  disappearance, 
and  as  the  disease  advances  they  are  perceived  to  fade  away  alto- 
gether. Eventually,  the  longitudinal  striae  also  disappear.  At  the 
same  time,  the  muscular  fibril  he-  break  up  into  granules,  and  then 
undergo  regressive  metamorphosis  into'  fat.  It  is  not  uncommon  to 
see  a  bundle  of  fibrilloe,  in  one  part  of  which  the  transverse  striae 
only  have  vanished  ;  in  another,  the  longitudinal  ;  in  another,  the 
process  of  disintegration  complete  ;  and  in  another,  oil-globules  occu- 
pying their  place.  Fat-corpuscles  are  frequently  found  deposited 
between  the  bundles  of  fibrillar.  After  a  time  the  fat  disappears,  and 
nothing  is  left  of  the  muscle  but  a  cord  of  connective  tissue  made  up 
of  the  perimysium. 

Sometimes  the  interstitial  fat  is  deposited  in  such  large  amount  as 
to  take  away  from  the  atrophied  parts  all  appearance  of  emaciation, 
and,  in  fact,  to  mask  the  essential  feature  of  the  disease.  Duchenne 
has  particularly  called  attention  to  this  circumstance,  and  has  given 
engravings  representing  patients  thus  affected. 

The  essential  points  in  the  morbid  anatomy  of  progressive  muscu- 
lar atrophy  are  no  longer  matters  of  doubt.  The  bearing  of  these 
points  on  the  real  nature  of  the  disease  is  next  to  be  investigated. 

At  the  outset  of  the  inquiry  relative  to  the  pathology  of  pro- 
gressive muscular  atrophy,  the  question  arises,  Is  it  an  affection 
of  the  muscles,  the  nerves,  the  sympathetic  system,  or  the  spinal 
cord  ? 

As  regards  its  being  a  disease  primarily  of  the  affected  muscles, 
Friedreich '  is  the  most  strenuous  contestant  in  support  of  the  affirma- 
tion. His  main  argument  is  that  lesions  are  found  in  the  muscles 
while  they  are  not  found  in  the  spinal  cord  or  nervous  system,  except 
in  a  few  instances.  But  he  neglects  to  state  these  very  important 
facts,  that  in  every  case  he  cites,  in  which  lesions  of  the  cord  were 
not  found,  the  examination  was  made  before  Lockhart  Clarke  had 
taught  us  how  histological  investigations  of  the  nervous  centres  were 
to  be  carried  on,  and  that  in  every  case  of  progressive  muscular  atro- 
phy, in  which  the  spinal  cord  has  been  examined  since  that  time,  and 
according  to  that  method,  disease  of  the  anterior  tract  of  gray  mat- 
ter has  been  found.  Thus  the  first  examination  which  he  cites  was 
1  "  Uebcr  Muskelatrophie,"  u.  s.  w.,  Berlin,  1873. 


PROGRESSIVE   MUSCULAR   ATROPHY.  515 

made  in  1858  ;  the  last  in  1867.  In  the  intervening  period  the 
lesions  of  the  cells  in  the  anterior  horns  did  not  attract  attention — 
were  not,  in  fact,  discovered.  Lockhart  Clarke,  Charcot,  Joffroy. 
Duchenne,  Hayem,  Pierret,  Prevost,  and  others,  had  not  made  the 
examinations  which  have  placed  the  existence  of  the  central  lesion 
beyond  a  doubt. 

Now,  as  to  the  relation  of  cause  and  effect  which  the  spinal  and 
muscular  lesion  bear  to  one  another,  opinions  vary,  and  the  ques- 
tion appears  to  be  one  which,  in  its  very  nature,  is  incapable  of 
being  positively  solved.  We  can  only  take  the  evidence  on  both 
sides,  and  determine  the  matter  according  to  what  strikes  us  as 
being  the  weight  of  testimony ;  and  this  appears  to  be  in  favor 
of  the  doctrine  of  primary  spinal  disease.  We  have  in  support  of 
this  view — 

1.  The  fact  that  those  cells  of  the  cord  are  diseased  which  are  in 
anatomical  and  physiological  relation  with  the  affected  muscles. 

2.  The  absolute  certainty  that  similar  lesions  of  the  anterior  horns 
of  gray  matter  will  cause  atrophy  of  muscles — infantile  spinal  paraly- 
sis, spinal  paralysis  of  adults,  acute  myelitis,  etc.  In  these  diseases 
we  know  from  the  central  as  well  as  from  the  peripheral  phenomena 
that  the  morbid  process  starts  from  the  spinal  cord.  We  have  hence 
evidence  that  atrophy  of  nerve-cells  will  give  rise  to  atrophy  of 
muscles. 

3.  On  the  contrary,  we  have  nothing  to  show  that  atrophy  of 
a  muscle  will  cause  inflammation  and  degeneration  of  spinal  nerve- 
cells. 

4.  If  the  diseaso  were  a  primary  affection  of  the  muscular  system, 
we  ought  to  find  the  nerves  diseased  at  their  extreme  peripheral  ter- 
minations in  the  muscles ;  such,  however,  is  not  the  case.  The 
ascending  neuritis,  which  Friedreich  assumes  to  exist,  is  not  shown  to 
be  a  pathological  entity.  Neither  the  patho-anatomical  facts  nor  the 
symptoms  of  progressive  muscular  atrophy  give  any  color  of  truth  to 
his  theory. 

It  is  not  to  be  doubted,  however,  that  peripheral  lesions  of  the 
nervous  system  will  cause  central  disease.  But  we  can  readily  con- 
cede that  much,  without  going  to  extreme  lengths  with  Friedreich. 

As  to  the  affection  being  a  primary  disease  of  the  nerves,  the  onlj 
evidence  we  have  of  that  doctrine  is  the  fact  of  the  atrophy  of  the 
anterior  roots  of  the  spinal  nerves  in  direct  relation  with  the  atrophied 

muscles.  Cruveilhier  regarded  this  condition  as  the  essential  lesion, 
mainly,  however,  because  he  was  unable  with  his  imperfect  means  of 
trcb  to  discover  tin-  morbid  process  in  the  cord.  This  nerve-atro- 
phy is  like  that  of  the  muscles — to  he  regarded  as  entirely  secondary 
to  (he  central  disease,  and  as  being  directly  dependent  thereon.  If  it 
were  primary  or  due  to  the  muscular  atrophy,  we  would  find  it  not  only 


516  DISEASES   OF   THE   SPINAL   CORD. 

manifested  in  the  anterior  nerve-roots  but  in  the  peripheral  extremi- 
ties ;  beginning  in  them  and  passing  along  the  trunks  of  the  nerves  to 
the  cord. 

When  we  come  to  consider  the  relation  of  progressive  muscular  at- 
rophy to  the  sympathetic  nervous  system  we  find  little  or  nothing  to 
warrant  us  in  considering  it  as  one  of  cause  and  effect.  It  is  true  that 
Jaccoud '  and  others  have  observed  lesions  of  the  sympathetic,  asso- 
ciated with  the  disease  in  question;  but  Charcot,  Vulpian,  and  Hayem, 
by  the  employment  of  the  most  approved  methods  of  research,  have 
failed  to  confirm  these  results;  and  quite  recently  M.  Lebimoff a  has 
most  thoroughly  and  conclusively,  in  a  case  of  undoubted  progressive 
muscular  atrophy,  investigated  the  sympathetic  nervous  system,  and 
has  found  neither  fatty  degeneration  of  the  nervous  element  nor  de- 
generation or  proliferation  of  the  neuroglia.  All  that  he  discovered 
was  a  deposit  of  pigmented  granulations  in  the  protoplasm  of  the  con- 
nective-tissue cells — a  condition  which  he  very  properly  ascribes  to  the 
general  exhaustion  and  the  cachectic  state  of  the  patient.  In  this  case 
the  characteristic  alterations  of  the  cells  of  the  anterior  horns  were 
very  pronounced. 

Hence  we  are,  I  think,  forced  to  conclude  that  progressive  muscular 
atrophy  is  not  primarily  a  disease  of  the  muscles,  the  nerves,  or  the 
sympathetic  system,  but  of  the  anterior  tract  of  gray  matter  of  the 
spinal  cord. 

As  to  the  nature  of  the  process  by  which  the  cells  are  destroyed 
there  is  every  reason  to  believe  that  it  is  a  very  slow,  chronic  inflam- 
mation. 

Relative  to  the  physiological  functions  of  the  cells  which  are  the 
seat  of  the  disease,  there  is  not  much  to  say  in  addition  to  the  remarks 
already  made  when  infantile  spinal  paralysis  and  spinal  paralysis  of 
adults  were  under  consideration. 

Progressive  muscular  atrophy,  pure  and  Uncomplicated,  is  unaccom- 
panied by  paralysis,  except  such  loss  of  power  as  is  directly  due  to  the 
diminution  of  the  volume  of  the  affected  muscles.  The  inference  is, 
therefore,  that  it  is  not  the  motor  cells  which  have  disappeared  or  be- 
come atrophied,  and  yet,  on  post-mortem  examination,  we  find  that 
nerve-cells  of  some  kind  have  been  diseased.  The  presumption  is,  and 
it  is  reasonable,  that  these  are  cells  which  are  specially  connected  with 
the  nutrition  of  muscles — trophic  cells — and  that  progressive  muscular 
atrophy  is  a  symptom  indicating  the  existence  of  disease  of  the  trophic 
cells.  The  very  existence  of  these  cells  is  a  matter  of  inference,  but  in 
my  opinion  the  argument  in  favor  of  the  affirmative  is  very  much 

1  "  Bulletin  de  la  socic-te  medicale  des  hopitaux,"  1864  ;  and  "  Traito  dc  pathologic 
interne,"  tome  i.,  1870,  p.  357. 

2  "  Recherches  sur  l'etat  du  systome  nerveux  sympathique  dans  un  cas  d'atrophie  mus- 
culaire  progressive  spinale  protopathique,"  etc.,  Archives  de  Phi/biologic,  1874,  p.  889. 


PROGRESSIVE   MUSCULAR   ATROPHY.  517 

strengthened  by  the  facts  furnished  by  the  morbid  anatomy  of  progres- 
sive muscular  atrophy.  Dr.  Handheld  Jones  '  has  recently  written  for- 
cibly against  the  existence  of  any  special  trophic  nerves,  and,  by  exten- 
sion of  reasoning,  trophic  nerve-cells.  But  he  was  unaware  of  the 
more  recent  researches  of  Duchenne  and  Joffroy,"  upon  which,  in  ac- 
cordance with  these  observers,  I  have  based  my  views  of  the  pathology 
of  progressive  muscular  atrophy,  and  to  which  I  have  already  alluded. 
We  have  only  to  take  into  consideration  the  phenomena  which  are  ex- 
hibited in  glosso-labio-laryngeal  paralysis  as  it  affects  the  tongue  and 
progressive  muscular  atrophy  attacking  the  same  organ,  to  perceive 
how  wide  is  the  difference  between  the  two  affections.  In  the  case  of 
a  lady  from  Rhode  Island,  now  under  my  care,  the  thenar  eminences  of 
both  hands,  certain  muscles  of  the  arms,  and  others  of  the  lower  ex- 
tremities, are  in  a  state  of  profound  atrophy.  One  side  of  the  face  is 
also  affected.  She  swallows  with  difficulty  and  speaks  with  great  indis- 
tinctness. Here  are  some  of  the  symptoms  of  glosso-labio-laryngeal 
paralysis  to  a  superficial  observer,  but  when  the  patient  opens  her  mouth 
the  tongue  is  seen  not  as  a  mass  of  reddened,  flabby,  inert  muscles  ly- 
ing torpid,  but  atrophied  to  a  marked  degree  on  the  left  side  and  capable 
of  being  moved  as  well  as  the  diminished  volume  of  muscular  tissue  will 
permit.  Here  we  have  atrophy  of  the  muscular  system  beginning  in 
the  upper  extremities  and  finally  attacking — still  preserving  its  charac- 
teristics— the  muscles  of  the  face  and  tongue. 

On  the  other  hand,  we  may  have  the  morbid  process,  which  gives 
rise  to  glosso-labio-laryngeal  paralysis,  extend  down  the  cord  and 
attack  the  cells  of  the  anterior  horns.  But  it  is  then  a  paralysis  which 
results,  not  an  atrophy,  and  the  lesions  of  the  anterior  horns  are  to  be 
classed  with  the  secondary  degenerations  of  the  cord. 

Are  we  not,  from  these  two  categories  of  cases,  still  further  war- 
ranted in  assuming  the  existence  of  motor  and  trophic  cells  both  in  the 
spinal  cord  proper  and  the  medulla  oblongata  ?  To  answer  this  ques- 
tion in  the  negative  it  appears  to  me  we  are  forced  to  disregard  some 
of  the  most  cogent  teachings  of  morbid  anatomy  and  pathology. 

Treatment. — The  most  approved  means  of  treatment  consist  in  the 
use  of  the  primary  or  galvanic  current  to  the  spine,  and  the  faradaic 
to  the  atrophied  muscles.  The  former  is  best  applied  by  placing  one 
pole  on  the  nape  of  the  neck  and  stroking  the  skin  on  each  side  of 
the  vertebral  column  with  the  other.  The  current  should  be  as  strong 
as  the  patient  can  endure.  A  seance  should  be  given  every  alternate 
day,  and  should  last  about  ten  minutes. 

The  faradaic  current  should  be  carefully  and  thoroughly  applied  to 

1  "Are  there  Special  Trophic  tferves?"  8L  George's  Hospital  Reports,  rol.  iii.,  1868, 
p.  89. 

2  "  De  I'atrophie  aignS  el  chroniqae  dee  cellules  Berceuses,"  etc,  Archives  de  Phi/si- 

X<>.  4,  1870,  p.  499. 


518  DISEASES   OF   THE   SPINAL   CORD. 

every  atrophied  muscle  within  reach  which  responds,  and  should  be 
powerful  and  slowly  interrupted.  In  those  muscles  which  do  not  con- 
tract to  the  induced  current  the  primary  may  be  employed,  but  such  a 
course  will  rarely  be  necessary,  the  muscle  being,  in  the  vast  majority 
of  cases,  beyond  the  reach  of  remedial  means.  It  is  probably  entirely 
atrophied. 

By  the  use  of  these  measures  I  have  succeeded  in  curing  three 
cases.  These  have  already  been  referred  to.  The  last,  a  man  whose 
thenar  and  hypothenar  eminences  were  markedly  atrophied,  and  in 
whom  the  flexores  carpi  ulnaris  and  radialis  were  already  affected,  came 
with  his  physician  to  my  clinic  at  the  University  Medical  College.  I 
advised  the  treatment  mentioned  ;  it  was  carried  out,  and  in  the  course 
of  two  months  the  muscles  were  almost  completely  restored.  The 
atrophy  showed  no  further  disposition  to  extend.  I  have  since  heard 
that  this  patient  entirely  recovered. 

If  there  is  the  least  suspicion  of  syphilis,  iodide  of  potassium  in 
large  doses  should  be  administered.  In  the  case  of  a  gentleman  affected 
with  progressive  muscular  atrophy,  with  an  undoubted  clinical  history 
of  syphilis,  and  who,  residing  out  of  New  York,  I  see  only  about  once  a 
month,  a  very  positive  arrest  of  the  disease  appears  to  have  resulted 
from  this  treatment.  When  he  first  consulted  me  the  right  thenar  and 
hypothenar  eminences  were  entirely  destroyed ;  the  interossei  and 
lumbricales  were  nearly  so.  All  the  muscles  of  the  forearm  were 
more  or  less  affected,  and  the  disease  was  manifesting  itself  in  the  left 
thenar  eminence,  which  was  already  decidedly  wasted.  He  was  at  first 
treated  by  electricity,  but  there  was  no  improvement,  and  while  this 
agent  was  being  used  the  left  triceps  showed  signs  of  atrophy,  and 
fibrillary  contractions  occurred  in  the  muscles  of  both  arms,  which  were 
not  yet  wasted,  and  in  those  of  the  trunk.  The  electricity  was  now 
discontinued  after  having  been  employed  over  six  weeks,  and  the  iodide 
of  potassium  was  administered  in  gradually-increasing  doses,  beginning 
with  ten  grains  three  times  a  day.  At  about  the  time  thirty-grain 
doses  were  reached,  the  fibrillary  contractions  ceased.  He  continued 
to  increase  the  doses  till  he  took  half  an  ounce  a  day.  There  were 
then  no  contractions,  and  no  further  extension  of  the  atrophy  had  taken 
place.  The  medicine  was  now  discontinued  for  ten  days,  when  it  was 
resumed  and  continued  as  before.  He  still  takes  the  iodide  in  gradu- 
ally-increasing doses  every  alternate  month,  up  to  forty  grains  three 
times  a  day.  A  year  and  more  has  now  elapsed  since  I  first  saw  this 
patient,  and  there  has  been  no  advance  of  the  disease  since  the  treat- 
ment with  the  iodide  was  begun,  and  no  fibrillary  contractions  in  any 
part  of  the  body  since  their  disappearance  nearly  a  year  since. 

A  few  cases  of  improvement  have  been  reported  as  occurring  from 
hydro-therapeutics. 

It  is  very  probable  that  the  majority  of  the  instances  in  which  amel- 


PROGRESSIVE  FACIAL  ATROPHY.  519 

iorations  or  cures  are  asserted  to  have  been  produced  by  one  thing  and 
another  were  not  in  reality  cases  of  progressive  muscular  atrophy. 
Every  physician,  whose  practice  is  extensive  in  the  class  of  nervous 
diseases,  has  doubtless  had  many  patients  consult  him  in  whom  the 
diagnosis  of  progressive  muscular  atrophy  has  been  made,  but  who 
were  affected  with  very  different  affections  from  that  very  intractable 
malady. 

b.  Progressive  Facial  Atrophy. 

The  remarkable  affection  now  to  be  described  under  the  name  of 
progressive  facial  atrophy  has  been  known  since  1825,  when  Parry  l  de- 
scribed the  case  to  which  all  subsequently  noticed  have  a  more  or  less 
close  resemblance.  Although  cases  were  subsequently  reported  it 
seems  to  have  attracted  little  attention  till  Lande,2  in  1869,  and  Fremy," 
in  1872,  published  their  monographs.  No  account  of  the  disease  has 
yet  appeared  in  this  country,  and  only  one  case  has  been  reported  in 
Great  Britain  since  Parry's  above  cited.  This  case,  described  by  Dr. 
Moore,4  of  Dublin,  appears  to  have  been  a  typical  one,  which  is  certainly 
not  the  fact  with  several  of  those  quoted  by  Fremy. 

The  disease,  which  was  called  by  Romberg — who  was  the  first  to 
give  it  an  independent  existence — trophoneurosis  facialis,  by  Moore  uni- 
lateral atrophy  of  the  face,  and  by  Lande  laminar  aplasia,  does  not 
seem  to  be  very  common.  Eleven  cases  have  been  collected  by  Lande, 
and  Fr£my  adduces  twenty-four  additional  ones,  several  of  which,  how- 
ever, are,  as  I  have  said,  not  cases  of  the  disease  in  question.  Three 
instances  only  have  come  under  my  observation. 

Various  theories  relative  to  its  essential  character  have  been  ad- 
vanced. These,  with  the  reasons  which  have  induced  me  to  consider 
it  as  having  affinities  with  progressive  muscular  atrophy,  will  be  fully 
brought  forward  under  the  head  of  morbid  anatomy  and  pathology. 

Symptoms. — The  first  case  which  occurred  in  my  own  experience 
was  that  of  a  lady  forty-one  years  of  age,  who  consulted  me  in  January, 
1874.  Twenty  years  previously  she  had  noticed  as  the  first  symptom 
a  very  slight  degree  of  weakness  in  those  muscles  of  the  left  side  of 
the  face  concerned  in  the  movements  of  the  lips,  so  that,  when  she 
attempted  to  smile  or  laugh,  the  mouth  did  not  expand  to  the  same 
extent  on  that  side  as  on  the  right. 

This  condition  lasted  several  months  without  giving  her  much  an- 
noyance, till  on  waking  one  morning  she  noticed  a  pale,  almost  white 
spot  on  the  skin  immediately  over  the  left  malar  bone.     This  was  of  a 

1  Tited  by  Romberg,  "  Lehrbucfa  der  Nervenkrankheiten  <l«v<  Menscben,"  Berlin,  1864. 
s  "Essai  but  I'aplasle  lamineuse  progressive,"  Pari-,  1868. 

3  "Etude  critique  de  la  trophonevrose  fadale,"  Paris,  1872. 

4  "  Case  <>r  Unilateral  Atrophy  of  the  Face,"  Dublin  Quarterly  Journal  of  Medical 
Science,  1852,  p.  245. 


520  DISEASES   OF  THE   SPINAL   CORD. 

sub-rotund  form,  and  gradually  enlarged  to  the  size  of  a  dollar,  becom- 
ing paler  in  hue  and  more  irregular  in  outline. 

Then  she  began  to  notice  that  there  was  a  lack  of  the  fullness  which 
characterized  the  right  side  of  the  face,  and  this  was  especially  evident 
at  the  situation  of  the  spot.     Here  a  depression  was  plainly  to  be  seem 

Then  a  second  depression,  but  this  time  without  being  preceded  by 
paleness  of  the  skin,  began  to  appear.  This  was  situated  at  about  the 
middle  of  the  chin,  half  an  inch  to  the  left  of  the  median  line.  This 
extended  most  toward  the  right  side,  and  in  the  course  of  two  years  had 
reached  the  median  line  and  had  a  length  of  about  two  inches  toward 
the  angle  of  the  mouth. 

During  the  time  that  these  depressions  were  extending  she  had  been 
subject  to  fibrillary  contractions  all  over  the  left  side  of  the  face. 

There  were  no  other  symptoms,  beyond  the  exceedingly  gradual  ex- 
tension of  the  first  depression,  for  fifteen  years.  Then  a  third  spot,  sit- 
uated on  the  skin  immediately  over  the  angle  of  the  jaw,  on  the  left 
side,  appeared  and  gradually  extended  as  had  the  first.  A  depression 
likewise  occurred  in  the  soft  parts  at  this  spot,  and,  extending,  finally 
reached  the  first  depression. 

When  she  consulted  me  there  was  a  marked  difference  in  the  size 
of  the  two  sides  of  the  face,  especially  the  lower  part.  The  skin  over  the 
forehead  on  the  left  side  was  glossy  and  the  belly  of  the  occipito-fron- 
talis  muscle  was  decidedly  thinner  than  that  of  the  opposite  side.  The 
left  eye  appeared  to  be  less  prominent  than  the  right,  the  temporal 
muscle  was  thinner,  and  the  masseter  was  certainly  not  so  thick  as  its 
fellow.  All  the  muscles  of  the  angle  of  the  mouth,  as  well  as  the  left 
half  of  the  orbicularis  oris,  were  atrophied.  The  depression  on  the  chin 
involved  the  depressors  of  the  lower  lip  and  angle  of  the  mouth.  The 
elevator  of  the  upper  lip  and  of  the  ala  nasi  was  not  affected. 

The  skin  over  the  left  side  of  the  face  was  apparently  attached  firm- 
ly to  the  parts  below,  and  did  not  admit  of  being  moved  or  pinched  be- 
tween the  fingers.  It  was  decidedly  thinner  than  that  of  the  other 
side. 

I  could  not  ascertain  that  there  was  any  atrophy  of  the  bones.  The 
pulsations  of  the  carotid,  temporal  and  facial  arteries  were  as  strong  on 
the  left  side  as  on  the  right. 

There  was  no  discoloration  or  falling  off  of  the  hair,  no  aberration 
of  sensibility,  no  unilateral  sweating,  and  no  difference  in  the  amount 
of  sebaceous  secretions  on  the  two  sides. 

The  motor  power  of  the  left  side  of  the  face  was  weaker  than 
that  of  the  right.  When  the  mouth  was  expanded,  the  action  was 
markedly  less  on  the  left  than  on  the  right  side.  The  left  buccinator 
was  thinner  and  weaker  than  the  right,  the  left  half  of  the  orbicularis 
oris  did  not  contract  to  the  same  extent  as  the  right  when  the  mouth 
was  pursed  up,  and  the  jaws  were  less  strongly  brought  together  on 


PROGRESSIVE   FACIAL   ATROPHY.  521 

the  left  than  on  the  right  side.  Yet  there  was  no  paralysis  in  any 
muscle,  and  each,  on  very  thorough  exploration  with  the  faradaic  cur- 
rent of  moderate  power,  contracted  well. 

Examined  with  the  aesthesiometer  the  sensibility  was  found  to  be 
intact.  At  no  time  had  there  been  numbness,  pain,  or  any  abnormal 
sensation. 

The  tears,  saliva,  and  buccal  and  nasal  mucus,  did  not  appear  to  be 
altered,  either  in  quality  or  quantity. 

The  tongue  was  not  involved,  and,  when  protruded,  came  out 
straight.     Deglutition  was  unimpaired. 

The  temperature  of  the  two  sides  of  the  face  was  examined  by  a 
delicate  thermometer,  but  no  difference  could  be  found  to  exist;  but  in 
October,  1875,  I  again  had  the  opportunity  of  examining  this  patient, 
and  then,  by  means  of  Dr.  Lombard's  thermo-electric  apparatus,  1  as- 
certained that  the  left  was  .7°  centigrade  lower  in  temperature  than  the 
right  side.     The  general  health  was  excellent. 

Although  not  allowed  to  have  a  photograph  taken,  I  obtained  the 
permission  of  this  lady  to  examine  the  muscular  tissue,  and  punct- 
uring the  buccinator  with  Duchenne's  trocar  I  succeeded,  with  some 
little  difficulty,  in  extracting  a  fragment  for  microscopical  investiga- 
tion. For  purposes  of  comparison,  I  operated  in  the  same  manner  on 
the  corresponding  part  of  the  opposite  muscle.  The  results  of  the  ex- 
amination will  be  given  when  we  come  to  the  consideration  of  the  mor- 
bid anatomy  and  pathology. 

A  second  case  came  under  my  observation  shortly  after  the  publica- 
tion of  the  foregoing  in  the  sixth  edition  of  this  work,  but  the  patient, 
a  woman  of  about  forty  years  of  age,  passed  from  my  notice  before  I 
had  the  opportunity  of  making  a  study  of  the  phenomena,  or  even  of 
making  notes  of  them.  My  recollection,  however,  is  clear  that  the 
muscles  supplied  by  the  facial,  the  motor  branch  of  the  fifth,  and  the 
hypoglossal,  were  the  seat  of  atrophy. 

A  third  case1  forms  the  subject  of  a  communication  read  before  the 
New  York  Neurological  Society,  March  2,  1880.  The  patient  was  a 
girl  fourteen  veins  old.  The  affection  was  of  gradual  growth,  and 
did  not  attract  marked  attention  till  about  two  years  previously  t<> 
my  seeing  her.  It  was  then  noticed  that  the  left  side  of  the  face  A\as 
different  from  the  right,  ami  careful  examination  showed  that  there 
were  t  wo  depressions  :  one  just  above  the  angle  of  the  mouth,  and  one 
just  below  and  a  little  external  to  the  other.  Subsequently,  the  one 
above   and    Blightly  in  front  of   the   left    ear  began    t<>   appear.      All   of 

them  have  continued  t<>  increase  up  to  the  presenl  time  (January  24, 

1881),  and  in  addition  there  is  a  decided  difference  in  the  size  of  the 

two  sides  of  the  face  (Fig.  56).     There  has  at  no  time  been  any  appar 

1  "  A  Que  of  I  e  Racial  Atrophy,  with  Remarks  <>n  the  Pathology  of  thi 

Dieea  e"Jouiiialof  Kervouaond  Mental  Diseases,  April,  18 


522 


DISEASES   OF   TOE   SPINAL   COED. 


ent  paralysis.  Occasionally  there  are  what  may  bo  called  paroxysms 
of  numbness,  extending  over  the  left  side  of  the  face  and  never  pass- 
ing the  mesial  line.  These  only  last  a  few  minutes.  At  no  one  of 
my  examinations  have  I  been  able  to  detect  any  loss  of  sensibility 


Fio.  5G. 


except  of  a  limited  region  over  the  left  half  of  the  orbicularis  oris 
muscle.  The  centres  of  atrophy  were  not  preceded  by  any  whiteness 
of  the  skin.  The  hair,  however,  is  markedly  thinner  on  the  antero- 
superior  auricular  centre  of  atrophy  than  on  the  sound  side. 

Examination  shows,  what  had  not  previously  been  noticed,  that 
the  left  half  of  the  tongue  is  much  smaller  than  the  right,  and  that 
the  palatine  arch  on  the  same  side  is  flatter  than  on  the  opposite  side. 
The  tongue  when  protruded  is  deflected  toward  the  affected  side. 
There  is  no  difficulty  of  swallowing,  no  defective  articulation,  no  loss 
of  taste,  and  no  deficient  sensibility  of  the  tongue  or  any  part  of  the 
mucous  membrane  lining  the  buccal  cavity. 

The  first  symptom  which  ordinarily  makes  its  appearance  is  the 
white  spot,  which  shows  an  evident  tendency  to  extend.  The  centre 
of  greatest  atrophy  is  in  intimate  topographical  relation  with  this 
spot,  and  it  is  here,  therefore,  that  the  depression  is  most  marked. 

The  skin  becomes  thinner,  as  is  well  perceived  when  a  fold  of  it  is 
pinched  between  the  fingers,  as  can  be  done  in  the  early  stage  of  the 
disease.     The  cellular  tissue  also  diminishes  in  volume. 

The  hair,  eyebrows,  eyelashes,  and  beard,  generally  either  fall  out 
or  lose  their  color,  changing  to  a  gray  or  even  perfectly  white  hue. 


PROGRESSIVE   FACIAL   ATROPHY.  523 

The  sebaceous  secretion  is  usually  less  on  the  affected  than  on  the  sound 
side.  Sometimes  the  larger  arteries  are  apparently  diminished  in  cali- 
bre, but  the  capillary  circulation,  as  evidenced  in  blushing,  is  as  active 
on  the  affected  side  as  on  the  other. 

The  muscles  have  generally  been  atrophied  both  in  thickness  and 
length.  Fibrillary  contractions  have  sometimes  been  observed.  It. is 
probable  they  would  be  generally  noticed  if  attention  were  directed  to 
them. 

It  is  rarely  the  case  that  sensibility  is  disturbed  ;  but  occasionallv 
neuralgic  pains  have  been  experienced.  The  cartilages  and  even  the 
bones  have  been  sometimes  the  seat  of  atrophy. 

The  special  senses  remain  intact,  and  the  secretions  of  the  tears,  the 
saliva,  and  the  buccal  mucus,  are  not  diminished. 

Of  the  eleven  cases  collected  by  Lande,  the  tongue  was  atrophied  on 
the  side  corresponding  to  the  facial  disease  in  five  cases,  and,  when 
protruded,  pointed  toward  the  affected  side. 

In  several  cases  the  atrophy  extended  to  the  veil  of  the  palate  and 
the  uvula;  but  the  function  of  deglutition  has  never  been  impaired. 

In  three  of  the  cases  cited  by  Lande,  the  atrophy  affected  the 
larynx.     Phonation  was  impaired  in  one  of  these  instances. 

In  none  of  Lande's  cases  in  which  the  point  was  inquired  into  was 
there  any  difference  in  the  temperature  of  the  two  sides.  In  five  of 
Fremy's  cases  the  affected  side  was  of  a  temperature  lower  from  a  few 
tenths  to  one  and  a  half  degree. 

In  no  case  has  there  been  complete  paralysis  of  any  muscle,  and  the 
portion  which  remains,  always  contracts  to  the  excitation  of  the  elec- 
trical stimulus. 

Fremy's  statistics  are  very  much  to  the  same  effect  as  those  of 
Lande,  though  they  are,  I  think,  open  to  the  objection  that  some  of  his 
cases  were  not  true  instances  of  the  disease.  Of  twenty-seven  cases 
cited  by  him,  of  which  details  are  given,  the  tongue  was  affected  eight 
times,  the  lips  nine,  and  the  veil  of  the  palate  five  times.  In  seven 
other  cases  no  statement  is  made  in  regard  to  these  points,  and  in  one 
it  is  vaguely  stated  that  there  was  buccal  atrophy.  In  four  of  these 
cases  the  affection  involved  at  the  same  time  both  lips,  the  tongue,  the 
veil  of  the  palate,  and  its  pillars  on  one  side. 

The  progress  of  the  disease  is  exceedingly  slow,  the  condition  exist- 
ing in  many  cases  for  several  years.  It  appears,  however,  to  be  dis- 
tinctly progressive  in  character.  No  death  has  occurred  from  it,  nor 
has  any  post-mortem  examination  been  made  with  the  view  of  inquiring 
into  the  nature  of  the  affection  in  any  patient  dying  of  an  intercurrent 
disease. 

The  accompanying  figures  from  Lande  represent  the  face  of  a 
woman  affected  with  progressive  facial  atrophy.  Tn  Fig.  ~>?  a 
front  view  of  the  countenance  is  given,  and  the  atrophy  of  the  left 


524 


DISEASES   OF   THE   SPINAL   CORD. 


side  is  clearly  shown.  Fig.  58  represents  the  left  side  of  the  face ; 
and,  for  purposes  of  comparison,  the  right,  unaffected  side,  is  given 
in  Fie.  59. 


Fig.  58. 


Fig.  B7. 


Fig.  59. 


Causes. — Little  is  known  relative  to  the  etiology  of  this  singular 
disease.  It  appears,  however,  generally  to  originate  during  early  or 
adult  life,  and  females  are  more  subject  to  it  than  males.  In  one  case 
it  ensued  after  a  fall  on  the  head,  and  in  one  it  followed  an  attack  of 
scarlet  fever.  No  evidence  of  hereditary  transmission  has  been  ad- 
duced. 

Diagnosis. — Lande  gives  a  long  list  of  diseases  from  which  facial 
atrophy  is  to  be  diagnosticated.  I  do  not  see  that  the  affection  is  likely 
to  be  confounded  with  any  other  than  progressive  muscular  atrophy, 
and,  perhaps,  in  some  cases,  in  its  early  stages  with  facial  paralysis. 

As  regards  the  first  of  these — progressive  muscular  atrophy — it 
rarely  if  ever  begins  in  the  face,  and  is  not  confined  to  that  part  of  the 
body  in  any  case.  Moreover,  there  is  discoloration  of  the  skin,  and  no 
cutaneous  atrophy.  Instead  of  being  tightly  stretched  over  the  soft 
parts  below,  the  skin  is  loose  and  can  be  easily  taken  up  in  a  fold  be- 
tween the  fingers.  When  the  face  is  its  seat,  as  it  sometimes  is,  second- 
arily, its  manifestations  are  not  confined,  as  are  those  of  facial  atrophy 
heretofore  observed,  to  one  side.  The  lesions  as  regards  the  face,  the 
tongue,  and  deglutition  and  phonation,  are  much  more  profound  in  pro- 
gressive muscular  atrophy  than  in  facial  atrophy.  . 

Relative  to  facial  paralysis  (Bell's)  there  can  ordinarily  be  no  diffi- 
culty in  making  a  diagnosis.  As  in  my  case,  there  may  be  a  marked 
weakness  of  the  facial  muscles  in  the  first  stage  of  the  disease  under 
notice.  But  the  mode  of  origin — Bell's  paralysis  coming  on  suddenly 
— and  the  fact  that  in  it  the  electric  contractility  of  the  muscles  is  al- 
ways diminished,  while  in  facial  atrophy  it  is  unimpaired,  will  suffice 
for  the  distinction. 

Prognosis. — No   case  of   a   cure  is  on  record.     The  affection  is  not 


PROGRESSIVE   FACIAL   ATROPHY.  525 

one  which,  as  heretofore  observed,  terminates  in  death,  but  it  is  evident 
that  there  are  cases  in  which  it  shows  a  tendency  to  involve  organs  of 
which  the  perfect  integrity  is  essential  to  life. 

Morbid  Anatomy  and  Pathology. — Bergson,1  who  appears  to  have 
been  the  first  to  study  the  disease  under  consideration,  regarded  it  as 
not  due  to  either  disorder  of  the  motor  or  sensory  nerves  or  of  those 
which  preside  over  the  glandular  secretions.  Without  indicating  the 
precise  primary  seat  of  the  affection,  he  looked  upon  it  as  essentially 
consisting  in  a  morbid  state  of  the  layer  of  cellular  tissue  situated  be- 
tween the  skin  and  the  muscles. 

Other  cases  were  reported,  and  in  1851  Romberg"  described  it  as  a 
"  tropho-neurosis  of  the  face,"  a  disease  characterized  by  atrophy  but 
of  which  the  primary  seat  was  unknown. 

Lasegue '  reported  a  case  in  1852  under  the  title  of  "  partial  atrophy 
of  the  face,"  and  Moore,4  in  the  same  year,  called  it  "  unilateral  atrophy 
of  the  face." 

None  of  these  writers  made  any  decided  effort  to  locate  the  disease 
or  to  interpret  its  real  nature  till,  in  1860,  Samuel,5  citing  a  well-marked 
case,  first  reported  in  1848  by  Hueter,  advanced  the  opinion  that  pro- 
gressive facial  atrophy  was  an  affection  of  the  trophic  system  of  nerves, 
and,  following  Moore,  he  designated  it  unilateral  atrophy  of  the  face. 

Then,  as  we  have  seen,  Lande,8  in  18G9,  wrote  a  very  complete 
monograph  on  the  disease,  which  he  called  "  laminar  aplasia  "  (aplasie 
lamineuse),  by  which  term  he  intended  to  convey  the  idea  which  he 
entertained  of  its  nature,  that  it  was  an  affection  of  the  cellular  tissue 
primarily. 

Subsequently,  Eulenburg T  very  fully  described  the  malady  under 
the  name  of  "  hemiatrophia  facialis  progressiva,"  and,  taking  into  con- 
sideration the  fact  that  the  manifestations  of  the  disease  are  exhibited 
in  those  parts  which  are  supplied  by  the  fifth  pair  of  nerves,  he  regarded 
it  as  the  result  of  a  lesion  of  this  system,  or  at  least  of  a  derangement 
of  its  function. 

Finally,  Fr6my,8  in  a  monograph  of  great  excellence,  enters  at 
length  into  a  consideration  of  the  pathology  of  the  disease,  and  con- 
cludes that  it  is  to  be  classed  with  those  trophic  neurotic  disorders  which 

1  "  Pe  Prosopodysmorphia  sivc  nova  Atrophia  facialis,"  Berlin,  1837,  cited  by  Lande. 

*  "  Klinische  Wahrnehmungen  und  Beobachtungen,"  Berlin,  1851. 

'  "Atropine  partielle  de  la  face,"  Archives  Generales,  tome  xxix.,  1852. 

4  "  Case  of  Unilateral  Atrophy  of  the  Face,"  Dublin  Quarterly  Journal  of  Medical  Sci- 
ence, 1852. 

5  "Pie  tropischen  Nervcn,"  Leipzig,  1860. 

*  "Essa:  sur  L'aplaeie  l:nnincuse  progressive  (atrophic  du  tissue  conncctif)  cclle  de  b 
face  en  particulicr,"  Paris,  1869. 

7  "  Lehrbuch  dor  functionellcn  Nervenkrankhciten,"  Berlin,  1871. 

8  "  Et'ide    critique   de   la   trcphoi.ovrose    facials  (l'hysiologie   patbologique),"    1' 
1872. 


526  DISEASES   OF   THE   SPINAL   CORD. 

have  been  studied  by  Romberg,  Samuel,  Charcot,  and  Vulpiau,  and 
that  it  essentially  depends  upon  derangement  of  the  trifacial  nerve. 

All  these  opinions  have  been  thoroughly  considered  by  Vulpian.1 
He  shows  very  conclusively  that  progressive  facial  atrophy  is  not  a 
disease  of  the  sympathetic  system,  and  then,  in  further  illustration  of 
his  views,  says  : 

"  Certain  peculiarities  of  this  affection  seem  to  indicate  that  the  tro- 
phic disorder  of  the  face  is  produced  by  an  intracranial  lesion.  But  the 
difficulties  are  so  great  in  the  way  of  imagining  that  a  limited  lesion 
could  give  rise  to  all  the  alterations  which  occur  in  the  face,  the  hair, 
the  buccal  cavity,  and  even  in  the  neck,  as  in  some  cases,  that  we  can 
see  how  M.  Lande  was  led  to  reject  the  idea  of  a  primitive  lesion  of  the 
nervous  system,  and  to  admit  only  a  protopathic  lesion  of  the  cellular 
tissue  of  the  face.  At  the  same  time  I  do  not  think  that  his  doctrine 
will  obtain  man}'-  partisans.  Indeed,  it  is  very  difficult  to  abandon 
the  idea  of  an  intracranial  lesion  as  the  cause  of  the  trophoneurosis. 
This  affection  is  produced  in  a  certain  number  of  cases  as  a  consequence 
of  traumatic  violence  inflicted  on  the  head  or  face.  Its  development  is 
accompanied,  in  the  great  majority  of  cases  for  several  years,  with  pains 
of  greater  or  less  violence  seated  in  the  head,  ordinarily  toward  the 
fronto-temporal  region.  Sometimes  there  are  spasmodic  movements  of 
the  muscles  of  the  face  or  of  the  jaws.  In  some  rare  cases  there  has 
been  numbness  in  the  superior  extremity  of  the  opposite  side.  These 
are  the  circumstances  which  seem  to  point  to  a  cerebral  lesion.  But 
we  cannot  affirm  that  such  lesions  exist,  while  we  have  no  post-mor- 
tem examination  to  enlighten  us  on  this  point,  and  while  we  are  em- 
barrassed to  designate  a  seat  for  the  lesion,  which  can  reasonably  ex- 
plain all  the  phenomena  of  the  disease.  It  has  been  proposed  to  at- 
tribute the  trophoneurosis  to  a  lesion  of  the  ganglion  of  Gasser,  but  can 
we  cite  a  single  case  in  which  lesions  of  this  organ  have  existed  in  con- 
junction with  an  ensemble  of  symptoms  such  as  that  presented  by  the 
disease  under  notice  ?  If  it  be  true  that  the  greater  part  of  the  altera- 
tions produced  in  the  malady  are  in  the  region  supplied  by  the  trigem- 
inus, and  even  in  the  course  of  certain  of  its  branches  (cicatricial  de- 
pression of  the  forehead  in  the  course  of  the  frontal  branch),  we  are  com- 
pelled to  admit  that  it  is  not  so  with  all  the  changes  (for  example,  those 
of  the  neck,  rare,  it  is  true).  The  special  atrophy  which  is  shown  in 
the  affected  regions  is  not  easily  explained  in  the  present  state  of  our 
knowledge  by  the  modifications  of  nutrition  resulting  from  lesions  of 
the  trigeminus.  We  see  nothing  similar  to  the  lesions  of  facial  tropho- 
neurosis produced  as  a  consequence  of  experiments  made  on  this  nerve 
or  on  the  ganglion  of  Gasser.  We  ought  not  to  forget,  however,  the 
nutritive  troubles  of  the  cornea,  so  common  in  lesions  of  the  ganglion 
of  Gasser  and  rare  in  facial  trophoneurosis.  Then  in  some  cases  thorp 
1  "  logons  sur  Tapparcil  vaso-moteur,"  tome  ii.,  1875,  p.  432. 


PROGRESSIVE   FACIAL   ATROPHY.  527 

is  atrophy  of  certain  facial  muscles,  whatever  M.  Lande  may  say  to  the 
contrary  ;  and  we  do  not  know,  either  clinically  or  by  experimentation, 
that  muscular  atrophy  is  ever  directly  produced  by  alterations  of  the 
trigeminus  or  its  ganglion.  For  to  speak  only  of  the  tongue,  the  lat- 
eral half  of  which  is  so  often  atrophied  in  facial  trophoneurosis,  I  have 
demonstrated  that  section  of  the  lingual  nerve  is  not  followed  by  appre- 
ciable atrophy  of  the  lingual  muscles. 

"  The  difficulties  which  we  encounter,  when  we  attempt  to  connect 
the  trophoneurosis  with  a  lesion  of  the  trigeminus,  are  increased,  when 
we  seek  to  explain  the  production  of  this  disease  by  an  encephalic 
lesion  seated,  for  example,  in  the  vicinity  of  the  nucleus  of  origin  of 
the  fifth  pair. 

"  To  conceive  an  hypothesis  so  little  plausible,  we  would  be  forced  to 
suppose  the  existence  of  multiple  lesions  seated  in  one  of  the  halves  of 
the  isthmus  of  the  encephalon.  But  all  tentative  explanation  appears 
to  me  to  be  perfectly  vain,  since  we  are  ignorant  whether  there  is  or  is 
not  a  primary  lesion  of  the  nerves  or  the  nerve-centres.  We  can, 
however,  positively  affirm  that,  taking  into  consideration  all  the  char- 
acteristics of  facial  trophoneurosis,  it  is  not  due  to  vaso-motor  pertur- 
bation acting  on  the  parts  which  are  the  seat  of  the  disease." 

As  we  have  seen,  there  has  been  thus  far  no  examination  of  the 
nerve-centres,  the  nerves,  or  the  muscles.  But,  in  the  case  which  was 
under  my  observation,  I  obtained,  as  stated,  portions  of  the  sound  and 
atrophied  buccinator  muscles,  and  submitted  them  to  careful  micro- 
scopical examination.  The  result  was  that  I  ascertained  that  the  fibril- 
lae  of  the  atrophied  muscle  exhibited  no  evidence  whatever  of  degen- 
erative changes — the  transverse  and  longitudinal  striae  were  distinct, 
and  there  were  no  traces  of  fatty  degradation.  But  the  transverse 
diameter  was  reduced  to  about  one-third  the  normal  size,  as  is  seen  in 
the  cuts  herewith  given,  which  are  drawn  from  the  camera  lucida  to  an 
exact  and  uniform  scale  when  magnified  four  hundred  diameters.  In 
Fig.  GO  is  shown  a  single  fibre  from  the  right  buccinator  muscle,  and 
in  Fig.  Gl  three  fibres  from  the  corresponding  part  of  the  left  bucci- 
nator. Fig.  62  represents  a  transverse  section  of  the  right,  and  Fig. 
G3  of  the  left  buccinator  muscles. 

Examination  also  shows  that  not  only  is  the  diameter  of  the  fibrilhe 
markedly  diminished,  but  the  length  is  also  lessened,  as  is  evidenced 
by  the  fact  that  the  transverse  striae  are  very  much  closer  together  in 
the  atrophied  than  in  the  sound  fibrilhe. 

It  will  likewise,  he  perceived  that  there  is  in  the  affected  muscle  ;i 
notable  diminution  of  the  thickness  <>f  the  layers  <>!'  the  internal  periiny- 
sium,  or  connective  tissues,  which  separates  the  fibres  From  each  other. 
This  tissue  appears  to  be  somewhat  hypertrophicd  on  the  right  side. 

This,  therefore,  constitutes  the  firsl  positive  contribution  to  the 
morbid  anatomy  of  progressive  facial  atrophy,  hut,  small  as  it   is,  it 


528 


DISEASES   OF  THE   SPINAL   CORD. 


affords  very  important  indications  in  regard  to  the  nature  and  seat  of 
the  affection. 

In  the  third  case,  the  one  of  which  the  photograph  lias  been  given, 
I  obtained  by  like  means  portions  of  the  muscular  fibre  from  each 


Fig.  62. 


Fig.  63. 


side,  and  they  were  exhibited  to  the  Neurological  Society.  They  were 
taken  from  the  buccinators.  In  the  one  from  the  right  or  normal  mus- 
cle, the  primitive  bundles  are  seen  to  be  of  full  size  and  in  every  respect 
of  healthy  appearance.  In  the  left  or  affected  muscle,  the  bundles  are 
perceived  to  be  less  than  one  third  the  diameter  of  the  others,  and  to 
be  much  paler  in  hue.  There  is  no  trace  of  fatty  degeneration,  not  a 
single  fat-corpuscle  or  oil-globule  being  visible  anywhere.  The  differ- 
ence is  so  striking,  that  one  can  scarcely  resist  the  at  least  momentary 
belief  that  a  sudden  change  in  the  magnifying  power  has  been  made. 
Accurate  measurement  shows  that  the  bundles  of  fibres  from  the  sound 
muscle  are  of  the  average  diameter  of  ^|^  of  an  inch,  while  those  from 
the  unsound  muscle  are  only  ^^ o  °f  an  mcn.  The  size  of  the  fibres 
from  the  sound  side  is,  therefore,  greater  than  that  ordinarily  existing 
in  the  facial  muscles,  and  may  probably  be  indicative  of  hypertrophy. 

Thus,  in  two  cases  in  which  microscopical  examination  has  been 
made  of  the  muscular  tissue  in  progressive  facial  atrophy,  there  has 
been  found  an  identity  of  lesions — atrophy  without  degeneration.  I 
hence  feel  warranted  in  concluding,  at  least  till  these  results  are  suc- 
cessfully controverted,  that  this  is  one  of  the  concomitants  of  the 
disease. 

It  shows  that  progressive  facial  atrophy  is  not  one  of  those  diseases 
manifested  by  degenerative  changes  of  the  muscles  such  as  we  have 
seen  take  place  in  infantile  paralysis,  spinal  paralysis  of  adults,  pseudo- 
hypertrophic paralysis,  and   progressive  muscular  atrophy.      It  is  an 


PROGRESSIVE   FACIAL   ATROPHY.  529 

atrophy  pure  and  simple,  without  the  slightest  tendency  to  degen- 
eration. 

So  far  as  analogy  is  concerned,  there  is  a  marked  affinity,  not  to  say 
resemblance,  between  the  symptoms  of  progressive  muscular  atrophy 
affecting  the  muscles  of  the  face,  the  tongue,  and  the  pharynx,  and 
those  of  some  cases  of  progressive  facial  atrophy,  in  which  not  only  the 
face  is  involved,  but  also  the  tongue,  and  in  one  case  at  least  the  larynx. 
"We  have  seen  that  in  glosso-labio-laryngeal  paralysis  the  muscles  of 
the  same  regions  are  involved,  but  instead  of  atrophy  we  have  paralysis. 
Now,  when  we  come  to  seek  out  the  primary  seat  of  progressive  muscu- 
lar atrophy  affecting  the  face,  tongue,  and  throat,  and  that  of  glosso- 
labio-laryngeal  paralysis,  we  find  both  in  the  bulb  and  especially  in  the 
nuclei  of  origin  of  the  facial,  the  hypoglossal,  the  spinal  accessory,  and 
pneumogastric  nerves.  If  two  such  different  but  cognate  diseases  may 
occupy  the  same  anatomical  situation,  why  may  not  progressive  facial 
atrophy,  different  but  cognate,  be  also  an  affection  of  the  same  region? 
The  fact  that  the  atrophy  involves  other  parts  than  the  muscles,  is  no 
valid  objection  against  this  hypothesis.  We  have  seen  that  in  infantile 
spinal  paralysis  there  is  sometimes  an  atrophy  of  the  bones.  And  yet 
we  all  agree  to  consider  this  disease  as  a  primary  affection  of  certain 
cells  in  the  anterior  tract  of  gray  matter. 

The  examination  of  this  case,  as  of  the  two  others  I  have  witnessed, 
shows  that  muscles  supplied  by  the  motor  branch  of  the  fifth  nerve, 
by  the  facial  and  by  the  hypoglossal,  are  atrophied  ;  that  the  skin,  hair- 
bulbs,  cellular  tissue,  and  even  the  bone  (temporal),  are  similarly  affect- 
ed ;  and  that  there  are  sensory  disturbances  in  the  skin  supplied  by  the 
fifth  nerve.  Under  these  circumstances  I  arrive  at  the  conclusion  that 
the  nuclei  of  these  nerves  arc  the  primary  seat  of  the  disease  in  this 
case. 

The  only  other  view  that  it  appears  necessary  to  discuss  in  this  con- 
nection is  the  one  that  all  the  phenomena  may  be  the  result  of  primary 
Implication  of  the  fifth  nerve  or  its  nuclei.  The  involvement  of  the 
motor  nucleus  only  would  certainly  not  account  for  the  multiple  mus- 
cle lesions  observed  in  this  case  ;  the  only  muscle  affected  supplied  by 
the  motor  branch  of  the  fifth  nerve  is  the  temporal,  and  this  only  in  a 
very  limited  portion  of  its  substance.  We  have,  therefore,  merely  to 
inquire  as  to  the  implication  of  the  sensory  nucleus,  it  being  admitted 
that  the  motor  nucleus  is  to  some  extent  affected,  as  shown  by  the 
effect  produced   upon  the  temporal   muscle.      The   existence  of  a  third 

ro«.t,  as  contended  for  by  MerkeV  and  to  which  he  assigns  trophic 
functions,  can  scarcely  he  regarded  as  demonstrated  ;  and,  though  its 
probability  maybe  admitted,  we  need  not  in  the  present  state  of  our 
knowledge  take  its  possible  influence  into  consideration.  So  far  as  the 
derangements  of  sensibility  are  concerned,  it  is  conceded  that  they  are 

1  "Die  trophischeo  Wnrsel  der  Trigeminus,"  Ccnlralblaft,  1871,  p  902. 
35 


530  DISEASES   OF   THE   SPINAL   CORD. 

due  to  lesion  of  the  sensory  nucleus  or  of  the  nerve  itself  in  some  part 
of  its  course. 

Now,  how  far  could  a  lesion  of  the  nucleus  of  the  sensory  root  of 
the  fifth  nerve,  or  one  of  the  root  itself,  tend  to  produce  all  the  phe- 
nomena observed  in  this  case  and  others  of  progressive  facial  atrophy? 

If  the  intracranial  portion  of  the  nerve  be  divided,  we  meet,  in 
addition  to  loss  of  sensibility  in  the  parts  to  which  the  nerve  is  distrib- 
uted, with  an  invariable  series  of  results  which  are  entirely  different 
from  those  observed  in  progressive  facial  atrophy.  These,  however, 
are  intimately  related  to  the  function  of  nutrition.  Thus,  the  cornea 
ulcerates,  the  conjunctiva  becomes  inflamed,  the  glands  innervated  by 
the  nerve  have  their  functional  activity  diminished  or  altogether  ar- 
rested, and  occasionally,  apparently  by  "reflex  influence,  ecchymoses 
appear  in  the  lungs  and  stomach. 

Certainly  these  are  not  the  accompaniments  of  progressive  facial 
atrophy. 

The  phenomena  due  to  an  irritation  of  the  sensory  nucleus,  or  of 
the  nerve  in  any  part  of  its  course,  are  so  entirely  different  from  those 
characterizing  the  disease  in  question,  that  it  is  not  necessary  to  dwell 
upon  them  more  particularly. 

It  appears  to  me,  therefore,  that  all  the  atrophic  phenomena  present 
in  cases  of  progressive  facial  atrophy  are,  like  those  met  with  in  pro- 
gressive muscular  atrophy  and  spinal  paralysis  of  infants  and  adults, 
the  result  of  lesion  of  the  nuclei  of  motor  nerves — and  probably  of 
trophic  cells — forming  with  the  motor  cells  the  centres  of  origin  of 
these  nerves.  In  these  diseases  atrophy  takes  place  without  the  inter- 
vention of  any  sensory  nerve  or  sensory  root,  and  there  is,  therefore,  no 
necessity  for  the  introduction  of  the  sensory  part  of  the  trigeminus  into 
the  pathological  circle  presiding  over  progressive  facial  atrophy. 

So  far  as  the  motor  nerves  which  are  in  relation  with  the  parts  af- 
fected in  progressive  facial  atrophy  are  concerned,  we  know  very  well 
that,  in  other  diseases  in  which  their  functions  are  abolished  wholly  or 
in  part,  the  resulting  paralysis  is  always  accompanied  with  atrophy — 
the  nerves,  of  course,  containing  the  fibres  coming  both  from  the  trophic 
and  motor  cells  of  the  nuclei.  Take,  for  instance,  the  hypoglossal,  a 
purely  motor  nerve.  There  are  a  few  cases  on  record  in  which  the 
hypoglossal,  on  one  or  both  sides,  has  been  so  compressed  by  tumors 
that  its  functions  were  completely  interrupted,  and  this  interruption 
was  invariably  followed  in  a  short  time  by  atrophy.  Lockhart  Clarke 
divided  one  of  the  hypoglossal  nerves  in  a  rabbit,  and  Avithin  a  month 
after  the  operation  the  corresponding  half  of  the  tongue  was  markedly 
atrophied. 

It  may  be  well  to  allude  to  the  theory  that  progressive  facial  atro- 
phy is  the  result  of  lesion  of  the  sympathetic  system — if  only  to  say 
that  there  are  no  facts  which  tend  to  its  support. 


PROGRESSIVE   FACIAL   ATROPHY.  531 

In  an  interesting  paper  based  upon  two  cases,  Dr.  Bannister'  arrives 
at  the  conclusions  that  the  trophic  functions  of  the  fifth  nerve  are  es- 
pecially implicated,  and  that  in  some  cases  there  are  positive  lesions  of 
other  cranial  nerves.  He  considers  it  proved  that  the  symptoms  indi- 
cate a  chronic  trophic  asthenia  or  paralysis  rather  than  any  irritative 
action. 

I  am,  therefore,  of  the  opinion  that  progressive  facial  atrophy  is  an 
affection  of  the  trophic  cells  of  the  bulb  which  are  the  nuclei  of  the  fa- 
cial, the  hypoglossal,  and  the  spinal  accessory  nerves  ;  that  ordinarily 
the  lesion  does  not  extend  farther  than  the  facial,  but  that  sometimes 
when  the  tongue  is  involved  it  reaches  the  nucleus  of  the  hypoglossal 
and  occasionally  that  of  the  spinal  accessory.  In  these  cases  in  which 
there  are  aberrations  of  sensibility  the  nucleus  of  the  sensory  root  of 
the  fifth  pair  may  be  affected,  and  in  those  in  which  the  temporal  and 
masseter  muscles  are  involved  the  motor  root  may  also  be  implicated. 
Or  the  pain  which  is  sometimes  an  accompaniment  of  the  disease  may 
be  due  to  the  contracting  process  going  on  in  the  muscles  and  con- 
nective tissue  by  which  the  terminal  branches  of  the  trigeminus  are 
compressed. 

Why  the  atrophy  should  so  generally  affect  the  left  side  of  the  face 
in  preference  to  the  right,  I  do  not  pretend  to  explain  ;  but,  since  the 
recognition  of  aphasia  and  its  association  in  the  vast  majority  of  cases 
with  lesions  of  a  circumscribed  region  of  the  left  hemisphere,  we  need 
not  be  surprised  at  the  additional  instance  of  hemitopology,  incom- 
plete as  it  is,  afforded  by  progressive  facial  atrophy. 

Finally,  the  question  may  be  asked,  Why  should  the  manifestations 
be  restricted  to  one  side?  I  should  answer  that  I  do  not  know,  any 
more  than  I  am  aware  why  ptosis  or  external  strabismus  should  affect 
the  eyelid  and  eyeball  of  one  side  ;  or  why  hemi-chorea  should  exist ;  or 
why,  when  a  person  has  an  attack  of  cerebral  ha?morrhage,  he  should 
not  straightway  hare  another  on  the  opposite  side  of  his  brain. 

The  first  two  cases  reported  occurred  on  the  left  side,  then  there 
was  one  on  the  right,  and  then  eight  on  the  left.  If  the  third  case  had 
(-(•aped  observation,  we  should  have  had  to  appearance  a  uniform  im- 
plication of  the  left  side,  to  the  exclusion  of  the  right.  Now  about  a 
dozen  cases  an-  reported  as  involving  the  right  side. 

It  appears  to  me,  however,  that  the  indisposition  manifested  to  pass 
tin-  mesial  line  is  a  strong  argument  against  the  affection  being  a  local 
lesion  only. 

Treatment. — Slight  success  was  obtained  by  Hueter  and  Moore  by 
the  use  of  faradaic  currents  to  the  atrophied  region.     1  employed  both 

these  and  the  primary  current,  the   latter  to  the   nucha  as  well,  in  two 

of  the  cases  under  my  care,  but  without  perceptible  effect.     I  also  ad- 

i  "Progressive  fladal  ffemi-atropby,"  Journal  of  Net 

Lcr,  1876. 


532 


DISEASES   OF   TEE   SPINAL   CORD. 


ministered  strychnia  and  other  tonics  without  benefit.  This  treat- 
ment, however,  seems  to  be  indicated,  and  is  in  general  urged  by 
those  who  have  written  on  the  subject.  No  cure  has  yet  been  re- 
ported. It  must  be  borne  in  mind  that  diseases  which  are  slow  to 
advance  are  also  slow  to  recede. 


III. 

INFLAMMATION    LIMITED    TO    THE    POSTERIOR    TRACT    OF    GRAY    MATTER 
OF    THE    SPINAL    CORD. 

The  posterior  tract  of  gray  matter,  the  columns  of  Burdach,  or  the 
postero-external  columns,  and  the  columns  of  Goll,  or  postero-median 
columns,  are  probably  the  only  channels  by  which  sensations  reach 
the  brain  from  the  parts  below.  Recently  Gowers '  has  described  a 
tract  on  the  periphery  of  the  cord,  situated  externally  to  the  crossed 
pyramidal  tract  in  lower  levels  of  the  cord,  and  anteriorly  to  it  in 
higher  levels,  which  degenerates  upward.     This  distinguished  investi- 


i**!2SSr 


Fig.  64. 


Diagram  ot  a  section  of  the  spinal  cord  in  the  cervical  region.     (Gowers.) 

A.  C,  anterior  commissure.  P.  C,  posterior  commissure.  I.  g.  s.,  intermediate  pray  sub- 
stance. P.  Cor. ,  posterior  cornu.  C.  C.  P.,  caput  coruu  posterioris.  L.  L.  L.,  Lateral 
limiting  layer.  A.-L.  A.  T.,  antero-lateral  ascending  tract,  which  extends  along  the 
periphery  of  the  cord. 

gator  considers  that  the  sensations  of  pain  and  temperature  are  trans- 
mitted to  the  brain  through  this  tract,  but  as  yet  this  view  has  not 
been  confirmed  by  sufficient  evidence  to  make  it  conclusive.  The 
fibres  which  constitute  the  posterior  nerve-roots  do  not,  on  their  en- 

2  "Diagnosis  of  Diseases  of  the  Spinal  Cord,"  1879. 


INFLAMMATION  OF  THE  POSTERIOR  TRACT  OF  GRAY  MATTER.     533 

trance  into  the  cord,  follow  any  uniform  course.  Some  of  them  pass 
directly  over  to  the  motor  cells  in  the  anterior  horn  of  the  same  side  ; 
others  terminate  in  the  cells  of  the  posterior  horn  either  at  the  level 
at  which  they  enter  the  cord,  or  else  after  passing  upward  or  down- 
ward for  a  short  distance  ;  some  seem  to  approach  and  probably  end 
in  the  group  of  cells  situated  near  the  junction  of  the  posterior  horn, 
and  the  posterior  commissure  known  as  the  vesicular  column  of  Clarke  ; 
others  pass  by  way  of  the  posterior  commissure  to  the  column  of  Bur- 
dach  on  the  opposite  side  ;  and  others  again  enter  the  columns  of  Coll 
and  Burdach  on  the  same  side. 

The  column  of  Goll,  and  possibly  part  of  the  column  of  Burdach, 
are  made  up  of  long  fibres  which  pass  up  the  entire  length  of  the  cord 
and  decussate  in  the  pons.  This  tract  unquestionably  is  the  conduct- 
ing path  for  the  muscular  sense. 

The  tracts  through  which  sensations  of  pain,  touch,  and  temper- 
ature are  transmitted  to  the  brain  are  not  definitelydetermined.  To 
Brown-Sequard  we  are  indebted  for  a  knowledge  of  the  fact  that  the 
sensory  tract,  with  the  exception  of  the  muscular  sense,  decussates 
almost  immediately  after  entering  the  cord.  If,  therefore,  a  lateral 
half  of  the  spinal  cord  be  divided  so  as  to  include  the  whole  of  the 
gray  matter,  the  animal  upon  which  the  experiment  is  performed 
loses  sensibility  in  the  parts  below,  on  the  opposite  side  of  the  body, 
and — which  is  not,  however,  a  matter  of  present  inquiry — motion  on 
the  same  side. 

Brown-Sequard's  investigations  led  him  to  believe  that  sensory  im- 
pressions were  conducted  to  the  brain  through  the  posterior  horns  of 
gray  matter  ;  but  the  probability  is,  though  the  question  is  not  yet 
definitely  settled,  that  sensations  of  pain  and  temperature  reach  the 
brain  through  Burdach's  column,  passing  up  on  the  side  opposite 
to  that  on  which  the  nerve-roots  enter  the  cord.  The  sensation  of 
touch  may  be  transmitted  through  the  same  channel,  but  there  is 
some  evidence  which  points  to  the  partial  confirmation  of  Brown- 
Sequard's  theory,  and  perhaps  it  may  yet  be  shown  that  the  sense 
of  touch  may  reach  the  brain  through  the  posterior  columns  of  gray 
matter. 

Cases  in  which  phenomena  of  loss  of  motion  on  one  side  and  of 
sensibility  on  the  other  are  coexistent  from  spinal  disease  arc  by  no 
means  very  infrequent.  Several  such  have  been  under  my  care  in  hos- 
pital and  private  practice,  and  I  have  always  attributed  them  to  a 
lesion  of  one  lateral  half  of  the  cord  disturbing  the  power  of  motion 
on  the  same  side  and  of  sensation  on  the  other. 

r>ut  experiment  shows  that,  while  one  part  of  the  posterior  nerve- 
roots  passes  over  to  the  opposite  side  immediately  on  its  entrance  into 
the  cord,  another  part  passes  upward  and  another  downward.  The 
effect,  therefore,  of  a  limited  lesion  involving  one  lateral   half  of  the 


534 


DISEASES   OF   THE   SPINAL   CORD. 


cord  would  be  profound  anaesthesia  of  the  opposite  side  of  the  body 
and  a  slight  degree  on  the  same  side.  Accordingly,  in  such  cases  as 
those  I  have  referred  to,  there  is  always  a  trace  of  numbness  on  the 
side  the  motion  of  which  is  paralyzed.  The  action  of  a  lesion  of  one 
lateral  half  of  the  cord  in  only  slightly  diminishing  sensibility  on  the 

side  of  the  alteration  while  greatly 
lessening  it  on  the  opposite  side 
will  be  readily  understood  from  an 
examination  of  Fig.  Go  :  a,  the  left 
half  of  the  spinal  cord,  b  the  right 
half  ;  c,  a  right  posterior  root,  with 
its  ascending  fibres  d,  its  descend- 
ing e,  and  its  decussating  fibres  f ; 
g,  decussating  fibres  from  the  op- 
posite side.  A  lesion  of  the  right 
side  of  the  cord  at  h  will  produce 
great  loss  of  sensibility  on  the  op- 
posite side,  and  slight  loss  on  the 
same  side. 

With  this  brief  statement  of  the 
physiology  and  pathology  of  the 
subject,  I  leave  the  further  consideration  of  the  diseases  of  the  poste- 
rior tract  of  gray  matter  till  science  has  given  us  more  definite  in- 
formation than  we  now  possess  relative  to  its  functions  and  de- 
rangements. 


IV. 


INFLAMMATION    OF    THE    ANTERIOR    AXD    POSTERIOR    TRACTS    OF    GRAY 
MATTER    OF    THE    SPINAL    CORD. 

The  grajr  matter  of  the  spinal  cord  as  a  whole,  is  subject  to  at  least 
one  disease — tetanus — which,  according  to  recent  investigations,  is  in 
reality  a  central  myelitis.  Since  Lockhart  Clarke  in  1864  gave  the  re- 
sults of  his  examinations  on  this  subject,  other  data  to  a  like  effect  have 
been  published,  and,  though  differences  in  the  lesions  have  been  observed 
these  are  of  secondary  importance  to  the  main  fact  that  in  tetanus  the 
central  gray  matter  is  the  chief  seat  of  the  alterations.  The  circum- 
stance that  the  white  matter  has  also  been  found  diseased  no  more  in- 
validates the  correctness  of  the  statement  than  the  fact  that  a  patient 
dying  with  the  symptoms  of  pneumonia,  still  has  that  disease,  even 
though  there  be  a  patch  or  two  of  inflamed  pleura  as  a  secondary 
lesion. 

a.  Tetanus. 

Two  varieties  of  tetanus  are  generally  described  by  systematic 
writers — the  idiopathic  and  the  traumatic;  but,  as  they  are  character- 


TETAXUS.  53g 

ized  by  similar  phenomena,  differing  mainly  as  to  their  modes  of 
origination  and  severity  of  their  symptoms,  there  would  he  no  advan- 
tage in  eonsidering  them  separately. 

Symptoms. — The  first  symptom  to  make  its  appearance  in  cases  of 
tetanus  is  a  feeling  of  pain  or  oppression  in  the  epigastric  region.  In 
the  beginning  it  does  not  attract  much  attention,  but,  as  the  disease 
advances,  it  becomes  exceedingly  severe,  and  adds  greatly  to  the  dis- 
comfort of  the  patient. 

Soon  after  the  occurrence  of  this  pain  uneasiness  is  generally  ob- 
served about  the  throat.  This  is,  perhaps,  no  more  than  a  sense  of 
stiffness  of  the  muscles  concerned  in  deglutition,  but  it  is  not  long 
before  swallowing  is  impeded  to  a  considerable  extent.  With  these 
symptoms  there  are  ordinarily  mental  and  physical  depression,  sensa- 
tions of  chilliness,  and  a  general  feeling  of  malaise. 

The  foregoing  constitute  a  prodromatic  or  formative  stage,  which 
may  last  a  few  hours  or  several  days,  and  which  is  occasionally  over- 
looked when  the  disease  is  intense  and  rapid  in  character. 

In  the  next  stage  the  epigastric  pain  is  still  a  prominent  symptom. 
It  is  seated  just  below  the  sternum,  and  generally  extends  backward  to 
the  spinal  column.  It  appears  to  be  due  to  spasm  of  the  diaphragm,  so 
that  this  muscle  is  among  the  first,  if  not  the  very  first,  to  be  affected 
in  the  vast  majority  of  cases.  The  difficulty  of  swallowing  increases, 
and  then  the  muscles  of  the  jaws  become  contracted,  constituting  the 
condition  known  as  trismus  or  lockjaw.  At  first  there  is  only  stiffness 
of  these  muscles  with  those  of  the  neck,  but  gradually  they  become 
rigid,  and  the  patient  experiences  difficulty,  if  not  impossibility,  in 
opening  the  mouth.  The  facial  muscles  do  not  escape,  and  an  expres- 
sion like  the  risus  sardonicus  is  produced  from  the  retraction  of  the 
angles  of  the  mouth,  the  elevation  of  the  alas  nasi,  and  the  expansion 
of  the  nostrils.  At  the  same  time  the  eyes  are  staring,  the  brows  cor- 
rugated, and  the  countenance  anxious  or  wearied  in  appearance. 

Sometimes  gradually,  at  others  suddenly,  the  morbid  action  extends 
to  other  muscles.  Generally  it  passes  to  those  of  the  neck,  the  back, 
and  the  loins,  causing  violent  contraction,  and  bending  the  body  back- 
ward. This  state  is  called  opisthotonos.  The  contraction  of  the  power- 
ful muscles  referred  to  is  so  great  as  to  cause  the  body  to  assume  the 
form  of  an  arch,  the  head  being  thrown  far  hack,  the  abdomen  pro- 
truded, and  thus,  if  the  patient  were  placed  on  his  back,  only  Ihe 
occiput  and  lie.ls  would  touch  the  bed.  Opisthotonos  is  the  usual  va- 
riety of  spasm. 

Two  other  forms  are  occasionally  met  with.  In  one  of  thes< — em« 
prosthotonos — the  body  is  bent  forward  from  the  contraction  of  the 
thoracic, abdominal,  ami  pelvic  muscles.  In  the  other— pleurostbotonos — 
it  is  bent  laterally.  This  latter  may  be  met  with  in  opisthotonos,  owing 
to  the  muscles  on  one  side  being  more  strongly   affected   than   on  the 


536  DISEASES   OF   THE   SPINAL   CORD. 

other.  Both  emprosthotonos  and  pleurosthotonos  arc  rare.  Of  very 
many  cases  of  tetanus  that  have  been  under  my  observation,  I  have 
only  seen  the  former  four  and  the  latter  three  times.  The  spasms 
characteristic  of  the  disease  are  touic;  but,  though  they  do  not 
entirely  relax,  they  are  marked  by  more  or  less  exacerbation,  accord- 
ing to  the  severity  of  the  attack  and  the  care  taken  of  the  patient. 
Any  cause  calculated  to  excite  reflex  action  will  induce  an  acces- 
sion. Thus  the  contact  of  the  bedclothes  with  the  body — the  legs 
especially — the  touch  of  the  hand,  the  forcible  shutting  of  a  door,  the 
rumbling  of  carriages  in  the  street,  even  the  blowing  of  a  breath  of 
air  on  the  skin,  may  produce  an  aggravation  of  the  spasm.  Even 
without  any  apparent  excitation  these  fits  occur.  They  are  marked 
by  great  pain,  and  may  be  so  violent  as  to  break  the  teeth,  and  the 
bones  of  the  legs,  and  tear  the  large  muscles  of  the  thigh.  During 
their  continuance,  and  often  when  they  are  not  present,  the  pain  at 
the  pit  of  the  stomach  becomes  unendurable,  and  the  patient  may 
lose  consciousness  through  its  intensity.  I  have  several  times  seen 
this  event  occur. 

The  tonic  rigidity  of  the  muscles  of  respiration  induces  diffi- 
culty of  breathing,  and  the  same  result  may  ensue  from  spasmodic 
closure  of  the  glottis.  Death  has  frequently  taken  place  suddenly 
from  one  or  other  of  these  causes.  With  all  this  muscular  excite- 
ment and  mental  disturbance  there  is  in  the  early  stages  rarely  any 
fever.  Toward  the  close,  however,  the  skin  is  hot,  and  the  ther- 
mometer often  ranges  from  105°  to  110°  Fahr.,  or  even  higher,  but 
the  pulse  remains  small  and  weak. 

Owing  to  the  difficulty  of  swallowing,  the  patient  suffers  from  hun- 
ger and  thirst,  and  thus  the  powers  of  the  system  are  still  further  re- 
duced.    The  bowels  are  always  obstinately  constipated. 

Wakefulness  is  generally  present  from  the  first.  When  the  patient 
does  sleep,  it  usually  happens  that  the  muscles  are  relaxed,  to  be  again 
suddenly  affected  with  spasm  as  soon  as  he  awakes. 

The  mind  is  clear  throughout,  even  in  the  most  severe  cases.  When 
loss  of  consciousness  occurs  from  extreme  pain,  it  is  from  syncope,  and 
not  from  any  implication  of  the  brain  in  the  essential  nature  of  the 
disease.  Death  usually  takes  place  by  apneea.  It  may,  however,  re- 
sult from  exhaustion,  and,  according  to  some  authorities,  from  the 
spasmodic  action  attacking  the  heart. 

The  duration  of  the  disease  is  very  variable.  The  shortest  case  on 
record  is  one  observed  by  Prof.  Robinson,  of  Edinburgh.  The  patient, 
a  negro  waiter,  cut  his  finger  with  a  piece  of  broken  china.  He  was 
immediately  seized  with  tetanus,  and  died  within  fifteen  minutes.  Mr. 
Poland  quotes  a  case  in  which  death  took  place  in  five  hours  ;  in  a  case 
cited  by  Lepelletier  in  a  few  hours  ;  in  one  by  Dr.  Jackson  in  twelve  ; 
in  one  by  Dr.  Leith  in  eighteen ;  and  in  one  observed  by  Mr.  Curling 


TETANUS.  537 

in  nineteen.'  The  shortest  duration  in  any  ease  I  have  witnessed  was 
twenty-six  hours,  though  I  believe  there  were  several  much  shorter, 
which  occurred  during  the  recent  war  in  this  country. 

The  average  period  of  duration  in  fatal  cases  is  from  the  third  to 
the  fifth  day.  Instances  in  which  it  has  been  prolonged  far  beyond 
this  limit  are  not  uncommon.  Hennen2  reports  a  case  in  which  it 
lasted  six  weeks,  and  then  the  patient  died  of  another  disease.  He 
reports  another  case  in  which  it  lasted  seven  weeks,  and  ended  in 
recovery.  I  have  seen  three  cases  in  which  it  extended  to  the  fifth 
week. 

The  period  which  elapses  between  the  reception  of  the  cause  and 
the  beginning  of  the  symptoms  is  also  subject  to  a  great  variation. 
In  a  case  already  cited  it  was  only  fifteen  minutes  ;  in  another,  quoted 
from  Dr.  Randolph  by  Reeves,3  the  spasms  ensued  immediately  after 
the  patient  was  stung  by  a  bee  ;  and  in  another,  which  occurred  in 
his  own  experience,  they  came  on  in  a  sensitive  female  immediately 
after  running  a  needle  into  her  finger.  There  is  doubt,  however, 
as  to  such  cases  really  being  tetanus.  In  the  last  one  cited  it  is 
stated  that  "the  body  and  extremities  were  rigid,  mouth  closed,  and 
the  jaws  fixed,  the  eyes  the  same.  At  short  intervals  the  whole 
body  was  affected  with  convulsive  shocks;  the  administration  of  a 
dose  of  chloroform  removed  them,  but  the  back  and  neck  remained 
rigid  for  three  days."  This  attack  was  probably  a  manifestation  of 
hysteria. 

In  eighty-one  cases  collected  by  Mr.  Curling,  the  disease  began 
between  the  fourth  and  fourteenth  days,  both  inclusive,  and  in  nine- 
teen on  the  tenth  day. 

The  following  table  from  Reeves  shows  the  period  of  the  occur- 
rence of  the  disease  in  three  hundred  and  fortv-thrce  cases  : 


From  15  to  17  days 25 

0 

9 


18  ' 

'    20 

•21    ' 

'    23 

24   ' 

1    2G 

-'7    ' 

1    29 

30  ' 

'    32 

Within  6,  12,  IS,  or  24  hours 12 

From  1  to    2  days 12 

"      3  "     5     "    87 

'<       G  "     8     "    91  "      2 4   "    2G     "    6 

"      9  "   12     "    77  "     27   "    29     "    9 

»     12  "   14     "    52  "      30   "    32     "    1 

Causes. — The  microbic  origin  of  many  cases  of  tetanus  seems  to 
be  beyond  dispute.  It  is  claimed  by  many,  and  perhaps  with  a  great 
deal  of  reason,  that  all  cases  of  tetanus,  whether  traumatic  or  idio- 
pathic, are  due  to  the  presence  in  the  system  of  the  tetanus  bacilli. 
The    power  of   this  microbe   to   induce    tetanus    was    first   successfully 

1  All  the  above  instances  arc  quoted  from  Reeves's  "Diseases  of  tin-  S;>in:il  Cord 
ami  its  Membranes,"  London,  ls:,s,  p.  ::st  ,■/  .*>■</. 

J  "Observation*  on  lome  important  Points  in  the  Practice  of  Military  Surgery,"  etc., 
Edinburgh,  1818,  p.  2G3. 

3  Op.  dl.,  p.  377. 


538  DISEASES   OF  THE   SPINAL   CORD. 

demonstrated  by  Rosenbaeh '  in  1886,  and  confirmed  later  by  Hoch- 
singer,3  Vanni  and  Garri,3  Bonome,4  and  others.  Bonome  describes 
the  bacillus  as  "  slender  and  bristle-like,  with  a  small  colorless  swell- 
ing at  each  end  like  the  head  of  a  pin."  This  bacillus  had  previously 
been  described  by  Nicolaier0  in  connection  with  cases  of  tetanus. 
Pus  containing  these  bacilli,  when  injected  into  the  muscles  or  be- 
neath the  skin  of  an  animal,  invariably  induced  tetanus,  but  when 
injected  into  the  blood  failed  to  do  so.  Hochsinger,6  however,  in  a 
later  article  on  this  subject,  claims  to  have  discovered  that  although 
the  tetanus  bacilli  is  not  found  in  the  human  blood  in  subjects  suffer- 
ing from  tetanus,  yet  the  blood  possesses  poisonous  qualities,  and, 
when  injected  into  animals,  invariably  induced  tetanus.  The  tetanus 
microbe  is  found  in  the  earth,  and,  according  to  Bonome,  in  the  dust 
and  mortar  of  old  buildings.  It  is  only  necessary  for  the  microbe  to 
be  deposited  in  some  open  wound,  or  to  be  introduced  into  the  sys- 
tem in  some  other  manner,  in  order  that  tetanus  should  be  developed. 
According  to  this  theory,  tetanus  cannot  be  considered  as  traumatis- 
mal  in  the  proper  sense  of  the  word,  the  wound  simply  being  the 
means  of  the  introduction  of  the  tetanus  microbe  into  the  system. 

The  most  common  cause  of  tetanic  infection  is  bodily  injury  of 
any  kind,  from  the  slightest  to  the  most  severe,  and  of  any  part 
of  the  body ;  although  wounds  of  some  parts,  as  of  the  thumb  and 
great-toe,  are  more  apt  to  be  followed  by  the  disease  than  those  of 
other  regions.  It  has  been  known  to  result  from  the  bite  of  a  tame 
sparrow,  from  the  sticking  of  a  small  fish-bone  in  the  pharynx,  from 
a  seton  in  the  thorax,  from  the  stroke  of  a  cane  across  the  back  of 
the  neck,  from  the  blow  of  a  whip-lash,  from  fractured  bones,  and 
from  every  other  imaginable  wound  or  injury.  In  a  case  under  my 
charge  in  this  city,  it  was  caused  by  a  splinter  of  wood  slightly 
scratching  the  palm  of  the  hand ;  in  another,  a  slight  punctured 
wound  of  the  foot  produced  it. 

Next  in  frequency  to  wounds,  tetanus  is  induced  by  exposure  to 
cold  and  damp.  This  is  the  exciting  cause  in  the  majority  of  cases  of 
idiopathic  tetanus,  and  it  increases  liability  in  those  who  have  suffered 
from  wounds.  It  was  not  uncommon,  during  the  recent  war,  for  the 
number  of  cases  of  tetanus  to  be  much  increased  immediately  after  a 
sudden  change  of  the  weather  from  dry  and  mild  to  wet  and  cold. 

It  has  also  apparently  been  caused  by  worms,  by  abortion  and  labor, 
and  by  diseases  of  the  womb.    Terror  has  the  reputation  of  having  in- 

1  Arclviv  fur  lelin.  Chir,,  Berlin,  1886-87,  xxxiv.,  p.  306. 

2  Ccntralblatt  fur  Baclcriol.  und  Parasitenk.,  Jena,  1887,  x.,  p.  1068. 

3  Sperimentalc,  Firenzc,  1887,  lix.,  p.  617. 

4  &wr  di  R.  Acad,  di  Med.  di  Torino,  1886,  3d  S.,  xxxiv.,  p.  759. 

6  "  Beitrage  zur  Aetiolo^ie  dee  Wundstarrkrampfc,"  Gottingen,  1885. 
6  Fortschritt  dcr  Med.,  February  5,  1888. 


TETANUS.  539 

duced  tetanus  in  one  case  reported  by  Dr.  Willan,  and  in  others  ob- 
served by  Hennen. 

In  the  form  occurring  in  very  young  children,  and  known  as  tris- 
mus nascentium,  it  appears  to  be  induced  by  inattention  to  the  cut  um- 
bilical cord. 

The  tendency  to  tetanus,  especially  among  soldiers  and  others  who 
have  been  wounded,  is  increased  by  poor  diet,  confinement  in  ill-venti- 
lated hospitals,  inattention  to  cleanliness,  and  neglect  to  give  proper 
care  to  the  wounds  they  may  have  received. 

Diagnosis. — The  only  affections  with  which  tetanus  is  liable  to  be 
confounded,  by  any  but  the  most  ignorant,  are  the  hysterical  simulated 
affection,  and  the  condition  induced  by  poisoning  with  strychnia  and 
other  substances  of  its  class. 

That  hysteria  can  simulate  tetanus,  as  well  as  almost  all  other  dis- 
eases, we  have  abundant  evidence.  A  case  has  already  been  referred 
to  in  this  chapter  which  was  evidently  hysterical,  and  several  others 
have  come  under  my  observation.  A  lady  now  under  my  charge  has 
repeated  attacks  of  hysterical  spasms,  during  which  her  jaws  are  tight- 
ly closed,  she  is  unable  to  swallow,  and  her  body  is  bent  backward  so 
as  to  assume  the  position  of  opisthotonos. 

Such  seizures  are  readily  distinguished  from  tetanus  by  the  facts 
that  they  are  unaccompanied  by  pain  or  real  distress,  are  of  very  tran* 
sient  duration,  and  are  accompanied  by  other  manifestations  of  hys- 
teria. 

From  the  artificial  tetanus  caused  by  strychnia,  the  diagnosis  is 
more  difficult;  for,  so  far  as  the  more  obvious  symptoms  go,  there  is 
such  a  great  similarity  that  even  the  most  skillful  diagnosticians  might 
be,  for  a  time,  undecided.  It  is  well  known  that  strychnia  is  not  unfre- 
quently  used  for  the  purpose  of  committing  murder  or  suicide,  and  it  is 
possible  so  to  employ  it  for  either  of  these  purposes  as  to  cause  its 
effects  to  extend  over  a  long  period  of  time,  and  thus  to  add  to  the 
difficulties  attending  the  discrimination.  Even  in  such  a  case,  however, 
the  diagnosis  can  be  made  if  due  care  and  a  thorough  inquiry  into  the 
history  of  the  case  be  made. 

In  the  first  place,  the  tetanus  of  strychnia  always  shows  itself  in 
the  lower  extremities  before  trismus  ensues.  The  legs  are  stretched 
widely  apart,  and  the  hands  are  generally  involved.  In  natural  tetanus, 
trismus  precedes  spasm  in  the  extremities;  indeed,  the  lower  extremi- 
ties are  rarely  affected  to  any  great  extent.  The  arms  generally  escape 
altogether. 

The  epigastric  pain,  which  constitutes  so  prominent  a  feature  of 
true  tetanus,  is  not  present  in  the  toxic  variety.  I  have  witnessed 
three  cases  of  poisoning  by  strychnia,  and  this  pain  was  not  complained 
of  in  either  of  them. 

In  the  tetanus  of  strychnia,  the  symptoms  are  developed  with  great 


540  DISEASES   OF   THE   SPINAL   CORD. 

rapidity,  and  death  takes  place  generally  within  a  half  an  hour,  al- 
though life  may  be  prolonged,  in  exceptional  cases,  somewhat  beyond 
this  period.  In  true  tetanus  it  is  very  rarely  the  case  that  death  takes 
place  within  twelve  hours,  and  ordinarily  not  till  several  days  have 
elapsed. 

In  those  cases  of  poisoning  by  strychnia  in  which  the  doses  have 
been  small,  and  administered  at  comparatively  long  intervals,  the  symp- 
toms are  mitigated  in  violence,  and  consequently  one  of  the  distinguish- 
ing features  of  the  two  affections  is  lost.  Still,  the  general  character 
and  sequence  of  the  phenomenon  are  the  same,  and  it  is  not  improbable 
that  careful  observation  and  inquiry  will  fail  to  elicit  the  true  nature  of 
the  case. 

Prognosis. — The  longer  the  time  that  has  elapsed  between  the  recep- 
tion of  the  injury  or  subjection  to  other  cause,  the  greater  is  the  prob- 
ability of  a  favorable  termination.  When  the  paroxysms  are  slight,  and 
the  intervals  between  them  long,  the  prognosis  is  also  more  favorable. 
A  low  bodily  temperature  is  a  favorable  indication.  On  the  contrary, 
an  elevated  temperature  is  of  fatal  augury.  The  duration  of  the  dis- 
ease is  likewise  an  important  element  in  the  prognosis;  and,  when  it 
has  lasted  over  a  week,  death  does  not  often  take  place.  Cases  are, 
however,  on  record  in  which  a  fatal  result  has  supervened  after  the 
affection  has. existed  for  several  weeks. 

Tetanus  is,  nevertheless,  one  of  the  most  fatal  of  maladies.  Dr. 
O'Beirne '  witnessed  two  hundred  cases  without  a  single  recovery. 
Hennen 3  never  saw  a  case  of  acute  symptomatic  tetanus  recover. 
McLeod  3  has  collected  and  analyzed  twenty-three  cases  which  occurred 
in  the  British  army  in  the  Crimea,  of  which  but  two  recovered.  Demme  * 
refers  to  eighty-six  cases  in  the  hospitals  in  Italy  during  the  campaign 
of  1859,  of  which  six  were  cured  ;  and  Hamilton  5  has  observed  eight 
cases,  of  which  three  recovered. 

Nine  cases  have  been  under  my  immediate  care,  of  which  there  were 
three  recoveries.  Of  the  many  cases  which  T  observed  in  the  course  of 
my  inspections  of  camps  and  hospitals  in  the  army  during  the  recent 
war,  I  do  not  know  how  many  terminated  favorably.  I  am  disposed, 
however,  to  believe  that  the  number  was  not  great.  Hamilton  states 
that  his  information  leads  him  to  think  that,  of  one  hundred  and  fifty 
cases  which  occurred  during  the  war,  the  recoveries  were  few. 

Morbid  Anatomy  and  Pathology. — As  regards  the  cord,  the  results 

of  post-mortem  examination  of  patients  who  have  died  of  tetanus  have 

1  "  Dublin  Hospital  Reports,"  vol.  iii.,  pp.  343,  378. 

2  Op.  cit.,  p.  262. 

'"Notes  on  the  Surgery  of  the  War  in  the  Crimea,"  London,  1858,  p.  153,  et  sc  q. 
Also  table,  p.  439. 

4  "  Militiir-chirurgische  Studien,"  Wiirzburg,  1861. 

5  "A  Treatise  on  Military  Surgery  and  Hygiene,"  New  York,  1866,  p.  595. 


TETANUS.  541 

Tip  to  a  comparatively  late  period  been  very  unsatisfactory.  Roki- 
tansky,1  in  chronic  cases,  found  a  proliferation  of  connective  tissue. 
Wedl,4  in  one  case,  discovered  increased  redness  of  a  portion  of  tlie 
spinal  cord.  Curling  3  declared  that  serous  effusion  with  increased  vas- 
cularity was  generally  observed  in  the  membranes  investing  the  medulla 
spinalis,  and  also  a  turgid  state  of  the  blood-vessels  above  the  origin  of 
the  nerves  ;  and  Wunderlich  4  regarded  the  lesions  as  consisting  in  a 
proliferation  of  the  connective  tissue  of  the  cord,  the  medulla  oblongata, 
and  the  cornua  cerebri  and  cerebelli. 

But,  in  1864,  Dr.  Lockhart  Clarke,5  after  a  careful  examination  of 
the  spinal  cords  of  six  persons  who  had  died  of  tetanus,  found  as  the 
uniform  results  an  abnormally  enlarged  condition  of  the  blood-vessels 
throughout  the  gray  matter,  especially  in  the  posterior  horns,  and 
granular  disintegration  of  the  nerve  tissue.  He  expresses  the  opinion 
that  tetanus  depends  (first)  upon  an  excessively  excitable  state  of  the 
gray  nerve  tissue  of  the  cord  induced  by  the  hyperemia,  and  morbid 
condition  of  the  blood-vessels,  and  the  exudation  and  disintegration 
resulting  therefrom,  and  (second)  that  the  spasms  are  the  result  of  the 
persistent  irritation  of  the  peripheral  nerves  by  which  the  exalted 
excitability  of  the  cord  is  aroused,  and  thus  the  cause  which  at  first 
induced  in  the  cord  its  morbid  susceptibility  to  reflex  action  is  subse- 
quently the  source  of  that  irritation  by  which  the  reflex  action  is 
excited. 

Subsequently,  Dickinson '  found  enlargement  of  the  blood-vessels 
throughout  the  gray  substance  of  the  cord,  with  perivascular  exuda- 
tion, rupture  of  the  blood-vessels  in  many  places,  and  granular  disin- 
tegration. 

Dr.  Clifford  Allbutt T  has  reported  the  results  of  his  examination  of 
the  spinal  cords  in  four  cases  of  tetanus.  He  found  diminution  of  the 
consistence  of  the  cord  of  various  degrees  and  situation  ;  haemorrhage 
in  two  cases  visible  to  the  naked  eye  ;  enlargement  of  the  blood-vessels; 
exudation  of  a  granular  plasma  surrounding  the  vessels  ;  enlargement 
of  the  cells  of  the  gray  matter,  and  the  granular  degeneration  of 
Clarke.     Outside  of  this  cord  he  found  the  nerve  thickened  and  con- 

1  "  Beitriige  zur  Pathologic  des  Tetanus,"    Virchow's  Archiv,  tome  xxvi.,  1862. 
9  "  Rudiments  of  Pathological  Histology,"  "Sydenham  Society  Translation,"  London, 
1855,  p.  276. 

*  "A  Treatise  on  Tetanus,"  etc.,  London,  1836. 

*  Archiv  dcr  Heilkundc,  1862. 

6  Lancet,  1884;  Medical  Timet  and  Gazette,  1865;  also,  more  fully,  "On  the 
Pathology  of  Tetanus,"  Medieo-ChirurgieaA  TrontacHone,  vol.  xlviii.,  1865,  p.  255. 

*  "Description  of  the  Spinal  Cord  in  a  Case  of  Tetanus,"  Medico-Chirurgieal  Traits- 
actions,  vol.  li.,  1808,  p.  287. 

1  "On  the  Changes  of  the  Spinal  Cord  in  Tetanus,"  "Transactions  of  the  Patho- 
logical Society  of  London,"  vol.  ucii.,  1871,  p.  27. 


542  DISEASES   OF  THE  SPINAL  CORD. 

gested,  and  bathed  in  inflammatory  products.     These  results  were  con- 
firmed by  the  subsequent  examination  of  Drs.  Clark  and  Dickinson. 

Dr.  Fox '  made  post-mortem  examinations  of  four  cases.  In  one 
the  only  abnormality  remarked  was  dilatation  and  distention  of  the 
vessels  of  the  spinal  pia  mater.  In  the  others  there  were  softening, 
haemorrhage,  amyloid  bodies,  in  the  gray  substance,  and  thickening  of 
the  vessels. 

Michaud 2  examined  the  cord  in  four  cases.  He  found  that  the  gray 
matter  presented  a  general  red  appearance.  The  vessels  were  enor- 
mously enlarged.  There  were  numerous  free  nuclei  and  foci  of  perivas- 
cular exudation.  The  gray  substance,  and  especially  the  posterior 
commissure,  was  the  seat  of  these  alterations  which,  according  to  him, 
consist  essentially  in  a  proliferation  of  the  nuclear  elements  of  the  con. 
nective  tissue.  The  appearance  which  Lockhart  Clarke  considers  to  be 
a  granular  degeneration,  Michaud  regards  as  being  due  to  these  nuclei 
existing  in  the  exudation  around  the  blood-vessels.  He  considers  teta- 
nus to  be  an  acute  inflammation  of  the  gray  tissue  of  the  cord. 

When  either  of  the  upper  extremities  is  the  seat  of  the  wound, 
which  is  the  primary  cause  of  the  disease,  the  lesions  of  the  cord  are 
found  in  the  cervical  enlargement,  and,  when  either  of  the  lower  limbs 
is  injured  so  as  to  induce  the  affection  in  question,  the  spinal  lesions 
are  found  in  the  lumbar  enlargement. 

The  nerves  coming  from  the  wounded  part  have  been  found  the 
seat  of  inflammation  by  Airlong  and  Tripier,8  and  by  Michaud.  In 
other  cases  they  have  not  exhibited  any  change. 

The  muscles  of  the  body  suffer  secondarily.  The  violent  spasmodic 
contractions  to  which  they  are  subjected  often  produce  ruptures  of  their 
tissue  and  extravasations  of  blood. 

On  the  other  hand,  it  has  often  happened,  especially  in  very  rapid 
cases,  that  nothing  has  been  found  which  could  fairly  be  regarded  as 
constituting  the  essential  feature  of  the  disease.  Billroth  b  affirms  that 
his  examinations  of  the  spine  and  nerves,  in  cases  of  tetanus,  have  thus 
far  given  only  negative  results,  and  this  is  in  accordance  with  the  ob- 
servations of  the  great  majority  of  pathologists.  But  these  discrepan- 
cies are,  I  think,  to  be  ascribed  to  defective  methods  of  examination, 
and  in  no  event  can  they  disprove  the  positive  data  obtained  by  others. 

It  is  contended  by  some  authors  that  tetanus,  like  hydrophobia,  is 
due  to  blood-poisoning.  The  fact,  that  a  condition,  so  nearly  resem- 
bling it  as  to  be  with  difficulty  diagnosticated  from  it,  may  be  caused 

1  "  Recherches  anatomo-pathologiques  sur  l'etat  des  systemes  nerveux  central  et  p&ri- 
ph6rique  dans  le  tetanus  traumatique,"  Archives  de  Physiologie,  1871,  p.  59. 

2  "The  Pathological  Anatomy  of  the  Nervous  Centres,"  London,  1874,  p.  355. 
8  Archives  de  Physiologie^  187<\  p.  244. 

*  Op.  cit. 

6  "  General  Surgical  Pathology  and  Therapeutics,  in  Fifty  Lectures,"  Hackley'a 
translation,  New  York,  D.  Appleton  &  Co.,  1871,  p.  353. 


TETANUS.  543 

by  the  injection  of  strychnia  into  the  blood,  appears  to  favor  this  view. 
However  this  may  be,  the  character  of  the  symptoms,  as  well  as  the 
anatomical  lesions,  indicates  the  spinal  cord  to  be  the  seat  of  the 
disease. 

The  first  symptoms  of  tetanus — spasm  of  the  diaphragm  and  tris- 
mus— indicate  that  the  initial  disturbance  in  the  spinal  cord  is  to  be 
found  at  as  high  a  level  in  the  cerebro-spinal  system  as  the  nucleus  of 
the  fifth  nerve.  The  increase  in  temperature  may  be  accounted  for 
by  the  implication  of  the  heat-producing  centre  which  Ott  '  has  shown 
exists  in  the  pons. 

The  spinal  cord  is  both  an  organ  for  the  generation  of  nerve-force, 
and  for  conducting  impressions  to  and  from  the  brain.  In  tetanus  it 
is  this  first-named  function  which  is  deranged,  and  this  is  shown  by 
the  great  exaltation  of  reflex  excitability  which  exists.  Everything 
capable  of  causing  a  reflex  movement  of  the  slightest  kind,  and  even 
excitations  which  in  health  would  be  altogether  unperceived  by  the 
cord,  augments  its  intrinsic  action  to  a  great  extent  where  tetanus  exists. 

Now,  we  are  able  to  produce  a  similar  increase  of  reflex  action  by 
strychnia  ;  and,  in  those  cases  of  disease  in  which  the  amount  of  blood 
in  the  cord  is  increased,  very  small  quantities  of  strychnia  produce  the 
characteristic  phenomena  of  stiffness  in  certain  muscles,  and  of  aug- 
mented reflex  excitability.  The  condition  is  aggravated  by  the  medi- 
cine ;  and,  if  we  had  no  other  facts  to  support  the  theory,  we  should 
be  warranted  in  concluding  that,  in  cases  of  strychnia-poisoning,  the 
amount  of  blood  in  the  cord  and  the  excitability  of  the  organ  are  both 
increased.  From  a  consideration  of  all  the  points  bearing  on  the  sub- 
ject, we  are  warranted  in  concluding  that  tetanus  essentially  consists 
in  a  morbid  exaltation  of  the  functions  of  the  spinal  cord  as  a  nerve- 
centre. 

Bernard  '  has  investigated  this  matter  with  his  usual  exactness.  He 
says  :  "  Strychnia  produces  convulsions  by  exaggerating  the  sensibility 
of  certain  parts  ;  it  also  causes  reflex  movements.  "We  have  seen  that 
flic  point  of  departure  is  in  the  sensitive  system  ;  for,  where  the  pos- 
terior roots  of  the  nerves  are  cut,  the  animal  dies  wit  boat  convulsions." 

An  experiment  performed  by  myself  and  my  friend  and  collabora- 
tor, Dr.  S.  Weir  Mitchell,"  shows  that  the  action  of  strychnia  is  to 
destroy  the  nervous  excitability  from  the  centre  to  the  periphery.  It- 
influence,  therefore,  must  firsl   be  exerted  on  the  spinal  cord. 

'"Tin'  II'  tt-Centres  >  =  f  the  Cortex  Cerebri  and  Tons  Varolii,"  Journ.  New.  and 
Meat.  Die.,  February,  I 

'  "  Lecons  sur  lee  effeta  dea  subatanoea  toxiquee  et  m6dicamenteuses,"  Paris,  1857, 
p.  386. 

•"Experimental   Researches  relative  to  Con-oval  and  Vao;  Two  New   Varieties  of 
Woorara,  the  South  American  Arrow-Poison,"  American  Journal  of  the  MedU 
July,  1859  ;  also  "  Physiological  Memoirs,"  Philadelphia,  1863,  p.  181,  d  &cq. 


544  DISEASES   OF  THE   SPINAL   COED. 

"  Under  the  skin  of  a  large  frog,  whose  left  sciatic  nerve  was  pre- 
viously divided,  a  few  drops  of  a  strong  solution  of  strychnia  were  in- 
troduced. Tetanic  spasms  ensued  in  two  minutes.  After  forty-five 
minutes  the  nerves  were  irritated  by  galvanism.  That  of  the  left  side, 
which  had  been  cut,  responded  energetically,  while  no  motions  could 
be  produced  through  the  uncut  nerve.  The  former  remained  excitable 
for  two  hours  later." 

Bernard l  asserts  that  the  action  of  strychnia  extends  no  farthei 
than  the  spinal  cord  ;  and  any  one  who  has  seen  a  frog  under  the  influ- 
ence of  this  substance  cannot  have  failed  to  notice  that  all  the  symp- 
toms indicate  exalted  spinal  action. 

We  are  therefore  led  by  observation  and  experiment  to  the  conclu- 
sion that  the  lesion  of  tetanus  is  seated  in  the  gray  matter  of  the 
spinal  cord,  and  that,  although  we  cannot  at  present  affirm  an  absolute 
identity  of  the  lesions,  in  each  case  we  have  enough  data  to  enable  us 
to  say  in  general  terms  that  tetanus  is  essentially  an  inflammatory 
affection  of  the  gray  matter  of  the  spinal  cord. 

Vulpian3  has  shown  that  strychnia  does  not  produce  organic  lesions 
of  the  cord.  He  kept  a  frog  for  a  month  under  its  influence,  and  on  kill- 
ing the  animal  found  the  cord  in  all  its  parts  in  a  perfect  state  of  integ- 
rity. But  on  this  point  there  is  a  difference  of  opinion,  Jacubowitsch 
and  Roudanowsky  asserting  that  the  processes  of  the  nerve-cells  are 
torn,  and  that  the  cells  themselves  are  often  ruptured.  It  is  not,  how- 
ever, probable  that  the  condition  of  the  cord,  in  poisoning  by  strychnia, 
ever  goes  beyond  the  point  of  hyperaemia,  which,  being  of  recent  oc- 
currence, would  disappear  on  death  supervening.  It  is  also  extremely 
probable  that,  in  the  cases  of  tetanus  in  which  recovery  takes  place,  the 
organic  derangements  discovered  by  Lockhart  Clarke  do  not  occur. 
This  is  his  opinion  :  Hyperemia  is  the  first  stage  of  all  inflammations, 
and  it  is  of  course  entirely  possible  that  the  morbid  process  should  be 
aborted  at  this  stage.  Indeed,  it  is  a  matter  almost  of  certainty  that  in 
some  fatal  cases  of  tetanus  the  pathological  action  has  not  gone  beyond 
the  hyperasmic  stage,  and  hence  the  absence  of  lesions  in  the  cases  ex- 
amined by  Billroth  and  others.  But  a  hyperemia  of  this  kind  is  of 
course  as  much  of  the  nature  of  inflammation  as  though  the  process 
had  reached  its  full  development. 

How  does  a  wound  of  the  extremity  or  trunk  of  a  nerve  cause  tet- 
anus? It  has  been  supposed  by  some  authors  that  there  was  a  neuri- 
tis in  each  case  which  advanced  centripetally  till  it  reached  the  spinal 
cord.     In  regard  to  this  point,  Mitchell 3  says  : 

"  There  is  a  prevalent  belief  that  tetanus  is  more  apt  to  arise  when 

1  Op.  ci(.y  p.  350. 

2  "  Convulsions  pendant  un  mois  chez  unc  grenouille  empoisonec  par  la  strychnia  ;  in- 
tegrite  complete  de  la  moelle  epinierc,"  Archives  dc  Physiologic,  18G8,  p.  306. 

3  "  Injuries  of  Nerves  and  their  Consequcnces,',  Philadelphia,  1872,  p.  147. 


TETANUS.  545 

large  nerves  are  slightly  hurt  than  on  other  occasions  ;  but,  although 
there  are  on  record  many  cases  where  this  terrible  malady  has  followed 
the  inclusion  of  nerves  in  ligatures,  in  the  mass  of  tetanic  histories  the 
causal  irritation  has  arisen  in  the  extreme  distribution  of  nerves,  and 
where  there  has  been  no  proof  of  precedent  injury  to  large  trunks. 
"Were  it  otherwise,  I  must  more  often  have  seen  tetanus,  whereas,  in 
two  hundred  recorded  instances  of  wounds  of  great  nerves  which  passed 
under  my  eye  during  the  Avar,  not  a  single  case  of  lock-jaw  was  seen, 
although  in  perhaps  one-half,  the  injuries  were  recent,  and  we  actually 
witnessed  a  part  of  the  process  of  healing.  In  fact,  the  tendency  tow- 
ard irritation  resulting  in  spasm  seems  to  increase  as  the  nerves  divide 
and  approach  the  skin.  Brown-Sequard  succeeded  once  in  causing  te- 
tanus by  leaving  a  rusty  tack  in  the  foot  of  an  animal.  I  have  never 
been  able  to  get  this  result  by  any  method,  nor,  in  some  seventy  sec- 
tions or  wounds  of  nerves  in  animals,  have  I  ever  encountered  it." 

The  experience  of  Dr.  Mitchell  on  this  point  is  sufficient  to  deter- 
mine it  against  the  existence  of  a  neuritis  extending  to  the  cord.  "Were 
there  any  such  cause  it  would  undoubtedly  be  more  apt  to  arise  from  a 
wound  of  the  trunk  of  a  nerve  and  to  extend  to  the  cord,  than  from  an 
injury  of  the  terminal  extremities.  Moreover,  the  facts  that  tetanus  has 
b  en  known  to  follow  in  a  few  minutes  after  the  reception  of  a  wound, 
and  that  there  is  no  pain  along  the  course  of  the  nerve,  are  directly  at 
variance  with  the  idea  of  a  peripheral  and  ascending  neuritis  as  the 
cause  of  the  spinal  lesions. 

Treatment. — There  is  scarcely  a  sedative  or  stimulant  remedy  in  the 
pharmacopoeia  which  has  not  been  employed  and  recommended  in  teta- 
nus. Aconite,  ether,  belladonna,  chloroform,  cannabis  Indica,  conium, 
opium,  tobacco,  Calabar  bean,  ice,  counter-irritants,  alcohol,  and  many 
other  substances,  have  been  used,  and  cases  reported  which  have  appar- 
ent lv  recovered  under  their  administration.  Then,  of  surgical  means, 
excision  of  the  injured  nerve  and  amputation  of  the  wounded  member 
have  also  been  recommended,  but  are  not,  I  believe,  practised  now. 
Latterly  the  bromide  of  potassium  and  hydrate  of  chloral  have  been 
employed  with  favorable  results. 

A  case  in  which  the  latter  agent  was  successfully  used  in  tetanus  is 
reported  by  Dr.  Wirth,1  of  Columbus,  Ohio.  In  about  a  month  the  pa- 
tient took  nine  ounces  and  two  drachms,  in  doses  of  from  thirty  to  fort  v 
grains,  at  times  as  often  as  every  one  and  a  half  hour.  In  this  case 
opium  in  large  doses  had  been  administered  without  effect.  A  number 
of  other  oases,  in  which  chloral  was  administered,  are  cited  in  the  Bame 
number  of  the  A"  >r  York  Medical  Journal,  in  which  Dr.  Wirth's 
appears,  in  several  of  which  it  was  successful. 

A  very  thorough  analysis  by  my  friend  1  >r.  !).  W.  Yandell,0  of  Louis- 

1  New  )'■>/•/'  Medical  Journal,  November,  )sT",  ]«.  410. 
-  American  Practitioner,  September.  1870,  [>.  152. 

36 


546  DISEASES   OF   TIIE   SPIXAL   COED. 

ville,  of  an  unpublished  report  on  tetanus,  by  Dr.  R.  O.  Cowling,  em- 
braces so  much  valuable  information  on  the  subject  that  I  quote  the 
summary  entire.  The  term  acute  is  applied  to  tetanus  occurring  within 
nine  days  of  the  injury,  and  chronic  to  oases  ensuing  after  nine  days  : 

"  ( \ihih(i)'  bean  was  given  in  thirty-nine  cases,  with  thirty-nine  per 
cent,  of  recoveries.  Of  these  reported  cures,  but  one  was  of  acute  teta- 
nus ;  five  others  were  in  cases  which  recovered  before  the  expiration  of 
fourteen  days.    Per  contra,  there  were  ten  deaths  from  chronic  tetanus. 

"  Indian  hemp  used  in  twenty- five  cases,  with  sixty -four  per  cent, 
of  recoveries,  of  which  three  cases  were  acute,  and  six  recovered  before 
the  symptoms  lasted  fourteen  days. 

"  Chloroform  relieved  seventy  per  cent,  of  thirty-five  cases,  nine  of 
which  were  acute,  and  eight  recovered  before  fourteen  days.  Three 
chronic  cases  died,  and  two  after  symptoms  lasted  fourteen  days. 

"  Ether. — Sixty  per  cent,  of  fifteen  cases  recovered  ;  five  acute  ; 
seven  inside  of  fourteen  days.     One  chronic  case  died. 

"  Opium. — Fifty-seven  per  cent,  of  one  hundred  and  sixty-five  cases 
recovered  ;  twenty -two  acute  ;  twenty -nine  before  the  fourteenth  day. 
Twenty-six  chronic  cases  were  lost,  and  four  after  the  disease  had  con- 
tinued fourteen  days. 

"  Tobacco  relieved  fifty  per  cent,  of  forty-one  cases  ;  six  acute  ;  six 
before  fourteen  days  of  the  disease.  Four  chronic  cases  died,  and  one 
after  fourteen  days. 

"  Quinine. — Seventy-three  per  cent,  of  fifteen  cases  recovered  ;  one 
acute  ;  three  before  fourteen  days.  Three  chronic  cases  ended  fatally, 
and  one  after  fourteen  days'  duration. 

"Aconite. — Eight  percent,  of  fourteen  cases  recovered;  none  acute; 
none  recovered  before  fourteen  days.     Death  in  one  chronic  case. 

"  Stimulants. — Eighty  per  cent,  of  thirty-three  cases  recovered  ; 
four  acute  ;  six  within  fourteen  days.  Six  chronic  cases  died,  and 
three  after  fourteen  days. 

"  Mercury. — Fifty-seven  per  cent,  of  seventy-five  cases  got  well  ; 
twelve  before  fourteen  days.  Seventeen  chronic  cases  were  lost,  and 
two  after  fourteen  days. 

"  Bleeding. — Fifty-five  per  cent,  of  fifty-eight  cases  recovered  ;  nine 
acute  ;  ten  before  the  fourteenth  day.  Seven  chronic  cases  were  lost, 
and  two  after  fourteen  days. 

"  Cold  Affusion. — Seventy-three  per  cent,  of  eleven  cases  recov- 
ered ;  three  acute  ;  three  before  fourteen  days.  Two  chronic  cases 
died. 

"  Ice-bags. — Seventy-seven  per  cent,  of  nine  cases  recovered  ;  one 
acute  ;  two  in  less  than  fourteen  days. 

"  Amputation. — Sixty  per  cent,  of  seventeen  cases  recovered  ;  four 
acute  ;  four  in  less  than  fourteen  days.  Three  chronic  cases  died,  and 
one  after  fourteen  days. 


TETANUS.  547 

"Division  of  nerve  relieved  seventy-five  per  cent,  of  three  cases  : 
one  acute  ;  one  before  the  fourteenth  day.     One  chronic  case  died. 

" Purgatives. — Sixty-six  per  cent,  of  seventy-four  cases  recovered  ; 
thirteen  acute  ;  twelve  before  fourteen  days.  Ten  chronic  cases  died, 
and  three  after  fourteen  days. 

"  Turpentine  relieved  seventy  per  cent,  of  sixteen  cases  ;  six  acute; 
four  before  fourteen  days.  Five  chronic  cases  died,  and  two  after 
fourteen  days." 

Among  the  conclusions  arrived  at  by  Dr.  Yandell  from  these  data 
are,  that  "recoveries  from  traumatic  tetanus  have  been  usually  in  cases 
in  which  the  disease  occurs  subsequent  to  nine  days  after  the  injury  ; 
that  when  the  symptoms  last  fourteen  days  recovery  is  the  rule,  and 
death  the  exception,  apparently  independent  of  the  treatment  ;  that 
chloroform,  up  to  this  time,  has  yielded  the  largest  percentage  of  cures 
in  acute  tetanus  ;  that  the  true  test  of  a  remedy  for  tetanus  is  its  influ- 
ence on  the  history  of  the  disease  :  does  it  cure  cases  in  which  the  dis- 
ease has  set  in  previous  to  the  ninth  day?  does  it  fail  in  cases  whose 
duration  exceeds  fourteen  days  ?  and  that  no  agent,  tried  by  these  tests, 
has  yet  established  its  claims  as  a  true  remedy  for  tetanus." 

It  is,  perhaps,  scarcely  necessary  to  say  that  I  fully  accord  with 
these  opinions. 

Judging  from  its  effects  upon  the  spinal  cord,  it  was  supposed  by 
Mr.  Morgan  that  woorara  injected  into  the  blood  might  prove  efficacious 
in  tetanus.  Experience,  however,  has  not  confirmed  this  view  ;  and  the 
researches  of  Dr.  Cowling  show  that  it  is  one  of  the  most  inefficient  of 
remedies. 

In  a  case  which  was  under  my  charge  fifteen  years  ago,  when  I  was 
one  of  the  surgeons  of  the  Baltimore  Infirmary,  I  injected  corroval — a 
remedy  which  the  investigations  of  Dr.  Mitchell  and  myself  had  proved 
to  be  antagonistic  to  strychnia — into  the  blood.  The  patient,  a  colored 
boy,  became  affected  with  tetanus  two  days  after  his  arm  had  been  am- 
putated by  my  friend  and  colleague  Prof.  Nathan  R.  Smith.  Cannabis 
Indica,  morphia,  and  chloroform,  had  been  used  without  effect,  when  at 
my  request  Prof.  Smith  turned  the  case  over  to  me,  in  order  that  cor- 
roval might  be  administered.  Two  drops  of  a  strong  solution  of  the 
substance  in  water  were  injected  into  the  cellular  tissue  of  the  forearm. 
.\l  the  time  the  pulse  was  160,  and  the  respirations  about  75.  There 
was  very  decided  opisthotonos.  In  three  minutes  (he  pulse  had  fallen 
to  152.  Two  more  drops  were  then  injected,  and  the  pulse  fell  to  144. 
As  it  soon  rose  again,  two  more  drops  were  injected,  when  it  fell  to 
132,  and  the  respirations  to  G4.  The  .spasms  still  continuing,  two  more 
drops  w<re  injected.  In  ii\>'  minutes  the  pulse  began  to  decline  rap- 
idly, and  in  ten  minutes  bad  fallen  to  90.  At  this  time  the  patient  had 
a  violent  tetanic  spasm,  and  during  its  continuance  the  pulse  became 
intermittent.     It  then  rapidly  wenl  down  to  40,  linn  t«>  80,  and  during 


548  DISEASES   OF   TEE   SPINAL   CORD. 

a  violent  spasm  the  patient  died.  From  this  record  it  will  he  seen  that 
at  no  time  did  the  corroval  exercise  the  least  effect  over  the  disease.1 

As  1  have  stated,  three  successful  cases  have  occurred  in  my  prac- 
tice. One  of  these  I  saw  in  consultation  with  Dr.  J.  Lewis  Smith,  of 
this  city.  It  was  traumatic,  and  had  ensued  two  weeks  after  a  wound 
of  the  foot  by  a  nail.  The  patient  was  treated  by  cannabis  Indica,  and 
the  persistent  application  of  ice  to  the  spine.  The  spasms  were  greatly 
lessened  in  force  and  frequency,  and  recovery  took  place  within  two 
weeks.  Another,  which  was  also  traumatic  and  acute — that  is,  making 
its  appearance  within  nine  days  after  the  injury — was  treated  accord- 
ing to  the  same  plan,  and  recovered  in  sixteen  days,  though  the  jaws 
remained  stiff  for  several  weeks  afterward.  The  wound  was  caused  b}* 
an  ice-pick  being  accidentally  thrust  through  the  hand.  The  third  case 
was  that  of  an  eminent  musician  of  this  city,  who,  while  drilling  with 
the  regiment  to  which  he  belonged,  injured  his  thumb  with  a  splinter 
from  the  stock  of  his  rifle.  The  first  evidence  of  tetanus  appeared  on 
the  twelfth  day.  The  attack  was  not  very  severe.  I  administered  the 
extract  of  cannabis  Indica  (Squires's)  in  doses  of  half  a  grain  every  two 
hours,  and  kept  up  the  application  of  ice  to  the  spine  continuously  for 
six  days.  There  were  several  violent  spasms  during  this  period,  and 
the  opisthotonos  was  well  marked.  At  the  end  of  a  week  the  cannabis 
Indica  was  Omitted  for  a  day,  but,  the  spasms  becoming  more  frequent 
and  severe,  it  was  resumed  as  before,  and  continued  with  tolerable  regu- 
larity for  ten  days  longer.  During  this  period  there  were  but  two 
spasms,  and  the  opisthotonos  became  less.  It  was  then  gradually  di- 
minished, and  on  the  twenty-fifth  day  was  left  off  altogether,  the  patient 
being  convalescent. 

I  am  disposed  to  think  that,  whatever  internal  medication  be  adopt- 
ed, the  application  of  ice  to  the  spine  is  a  measure  which  should  always 
form  a  feature  of  the  treatment. 


IV. 

INFLAMMATION    OF   THE   ANTERIOE   COLUMNS    OF   THE    SPINAL   COED 
(SCLEEOSIS    OF   THE    COLUMNS    OF  TURCK). 

Tiirck2  has  shown  that  the  anterior  columns  of  the  spinal  cord  are 
subject  to  a  chronic  inflammation  such  as  is  now  known  under  the  name 
of  sclerosis.     In  the  cases  which  he  described  the  morbid  process  in- 

1  "  Traumatic  Tetanus ;  Inoculation  with  Corroval ;  Deatb,"  by  Edward  Milholland, 
M.  D.,  Resident  Physician  at  the  Baltimore  Infirmary.  In  Maryland  and  Virginia  Medi. 
cal  Journal,  January,  1861,  p.  13. 

2  "  Ueber  Degeneration  eiuzelner  Ruckenmarksstrange,  welche  sich  ohnc  primare 
Krankheit  des  Gehirnes  odcr  Riickenmarks  entwickelt,"  SUzungsbcriehte  der  kaiserlichen 
Academic  der  Wisscnschaftcn,  Mat.  nat.  CI.,  1856,  p.  112. 


INFLAMMATION   OF   THE   LATERAL   COLUMNS.  549 

volved  symmetrically  a  small  region  on  each  side  of  the  anterior  me- 
dian fissure— that  part  which  is  designated  the  column  of  Turck. 
Microscopical  examination  showed  proliferation  of  the  neuroglia,  with 
degeneration  of  the  true  nerve-elements. 

The  course  of  the  disease,  the  symptoms,  causes,  etc.,  together  with 
the  morbid  anatomy  and  pathology,  do  not  differ  essentially  from  the 
corresponding  affection  of  the  lateral  or  crossed  pyramidal  tract  which 
is  more  frequent  and  is  more  thoroughly  understood.  Our  present 
knowledge  leads  us  to  the  inference  that  the  columns  of  Tiirck  are  in 
function  similar  to  the  lateral  columns.  The  number  of  cases  in  which 
they  have  been  found  altered  is  as  yet  small,  and  they  have  not  been 
very  thoroughly  worked  up.  In  some  cases  they  have  been  sclerosed 
in  conjunction  with  a  like  condition  of  the  lateral  columns. 

I  shall,  therefore,  pass  at  once  to  the  consideration  of  the  next 
division  of  the  subject. 

V. 

INFLAMMATION  OF  THE  LATERAL  PYRAMIDAL  TRACT  OF  THE  SPINAL 
CORD  ;  SPASTIC  SPINAL  PARALYSIS  (PRIMARY  SYMMETRICAL  LAT- 
ERAL sclerosis). 

Turck,1  who,  as  we  have  seen,  demonstrated  the  fact  that  the  ante- 
rior columns  of  the  cord  could  be  the  primary  seat  of  sclerosis  without 
any  other  region  participating  in  the  lesion,  also  showed  that  the  lateral 
columns  could  be  similarly  affected.  Turck's  investigations  were  al- 
lowed to  remain  scarcely  noticed  for  ten  years,  when  Charcot a  made 
like  observations  and  since  then  has  aided  in  establishing  it  as  a  dis- 
tinct pathological  condition. 

Symptoms . — The  chief  phenomena  of  the  disease  under  considera- 
tion are  paralysis  and  contraction  of  the  affected  limbs.  The  lower  ex- 
tremities are,  more  than  the  upper,  liable  to  be  the  seat  of  these  symp- 
toms. The  loss  of  power  is  very  gradual,  and  there  is  no  atrophy  be- 
yond the  general  emaciation  consequent  upon  diminished  use  of  the 
muscles.  Sensibility  is  not  in  general  affected,  but  in  some  cases  there 
is  more  or  less  pain  in  the  paretic  limbs  and  in  the  back  near  the  seat 
of  the  disease. 

The  paralysis  is  rarely  complete.  At  first  the  patient  merely  tires 
more  readily,  slight  exertion  fatigues  him,  and  this  is  especially  noticed 
in  the  muscles  which  flex  the  leg  upon  the  thighs,  and  the  consequent 
sensation  of  weariness  is  experienced  In  the  popliteal  space.  Some- 
times it  is  shown  in  the  sudden  relaxation  of  the  extensor  muscles  of 
the  leg  and  the  fall  of  the  patient  thereby;  at  others,  in  the  fact  that 

the  extensors  of  Hie  fool   bee e  weak,  allowing  the  toes  to  drop, 

.•mil  hence  causing  stumbling.  The  gait  then  becomes  characteristic. 
1  Op.  cii.,  p.  112.  -  V  Union  MidicaU,  1  *">•">. 


550  DISEASES   OF  THE   SPINAL  CORD. 

Owing  to  the  fact  that  the  patient's  extensor  muscles  are  weak,  he 
is  unable  to  lift  the  feet  high  enough  to  clear  the  ground,  and  hence 
he  throws  them  out  by  means  of  the  abductor  muscles  of  the  thigh,  and 
thus  causes  them  to  describe  an  arc  of  a  circle.  Then  in  putting  them 
down  the  heel  strikes  the  ground  a  longer  time  before  the  sole  than  it 
does  in  the  natural  gait,  and  hence  the  foot  comes  down  with  a  jerking 
motion.  This  is  the  ordinary  manner  of  walking  practised  by  a  person 
affected  with  the  disease  under  notice.  In  another  form  of  locomotion, 
the  body  is  moved  laterally  on  the  thighs,  first  to  one  side  and  then  to 
the  other,  in  such  a  way  as  to  cause  the  feet  to  be  raised  high  enough 
without  the  complete  action  of  the  extensor  muscles.  The  gait  is  there- 
fore similar  to  that  of  a  duck,  or  of  a  woman  with  a  very  wide  pelvis. 
The  motion  of  the  body  is  almost  serpentine,  and  the  feet  glide  over 
the  ground  barely  lifted  high  enough  to  avoid  contact. 

In  both  the  methods  of  walking  the  patient  requires  support.  At 
first  a  cane  answers,  then  he  comes  to  crutches,  and  eventually  the  as- 
sistance of  an  attendant  becomes  necessary. 

As  a  consequence  of  the  paralysis,  and  the  contractions  which  event- 
ually ensue,  the  movements  are  often  complicated  and  sometimes  ren- 
dered impossible  by  the  legs  becoming  interlocked  at  every  attempt  to 
walk.  In  a  patient  from  Connecticut  under  my  care,  not  long  since, 
this  difficulty  was  a  very  prominent  feature,  and  though  the  muscles  of 
flexion  and  extension  were  sufficiently  strong  to  allow  of  his  walking, 
those  which  abduct  the  thighs  were  so  materially  paralyzed,  and  the 
adductors  were  so  greatly  contracted,  as  to  produce  the  condition 
mentioned. 

Reflex  movements,  so  far  from  being  lessened,  are  generally  exalted  ; 
and  this  is  especially  true  of  the  "  tendon  reflex,"  as  exhibited  when  one 
leg  is  crossed  over  the  other  and  a  smart  blow  given  with  the  edge  of 
the  hand  over  the  tendon  of  the  quadriceps  extensor,  just  below  the 
patella.  The  leg  is  suddenly  extended,  and  bounds  much  higher  than 
it  normally  does  under  like  excitation.  An  exaggerated  "  knee-jerk," 
hoAvever,  unaccompanied  by  other  symptoms  of  disease  of  the  lateral 
pyramidal  tract,  is  of  no  importance  whatever.  The  electrical  con- 
tractility of  the  muscles  remains  unimpaired.  The  "ankle  clonus," 
which  consists  of  an  alternating  spasm  and  relaxation  of  the  gastroc- 
nemius, can  always  be  obtained,  except  in  some  well-advanced  cases, 
by  supporting  the  weight  of  the  patient's  leg  and  then,  grasping  the 
foot  firmly,  suddenly  extending  it,  when,  if  the  conditions  are  favor- 
able, the  foot  will  be  thrown  into  rapid  vibrations  of  flexion  and  ex- 
tension. In  some  patients  who  have  been  afflicted  with  the  disease 
under  consideration  for  a  long  time  the  muscles  of  the  leg  become  so 
stiff  and  rigid  that  the  ankle  clonus  cannot  be  obtained,  and  even 
the  exaggeration  of  the  knee-jerk  cannot  be  demonstrated. 

Sometimes  the  contractions,  which  are  so  prominent  a  feature,  re- 


INFLAMMATION   OF   THE   LATERAL   COLUMNS.  551 

lax,  but  they  again  supervene,  and  generally  persist  with  more  or  less 
intensity  till  the  closing  stages  of  the  disease,  when  the  power  of  the 
cord  becoming  exhausted  entirely,  and  all  the  muscles  being  paralyzed, 
the  spasmodic  action  ceases. 

A  very  remarkable  case  is  one  reported  by  Charcot,1  of  a  woman 
who,  after  several  hysterical  attacks,  was  seized,  after  having  been 
greatly  frightened,  with  a  violent  paroxysm  of  hysteria,  which  was 
soon  followed  by  a  general  trembling,  accompanied  by  a  weakness  of 
the  limbs.  At  the  end  of  a  month  the  feebleness  was  such  that  she 
could  not  leave  her  bed.  About  the  same  time  the  trembling  ceased, 
but  was  succeeded  by  a  contraction  which  affected  at  first  the  extremi- 
tiea  of  the  left  side,  but  in  the  course  of  three  weeks  involved  those  of 
the  ri^ht  side  also.     The  neck  also  became  ri<rid. 

All  these  phenomena  persisted,  they  even  increased  so  that  in  the 
early  part  of  1850  she  was  admitted  into  the  Charitc. 

At  that  time  she  was  confined  to  her  bed  in  the  dorsal  decubitus, 
not  being  able  to  move  her  limbs.  Her  general  health  was  good,  and 
her  cerebral  functions  were  normal.  The  muscles  of  the  neck  were 
painful  and  stiff.  The  skin  on  the  left  anterior  part  of  the  thorax  was 
hyperresthetic,  the  condition  being  exactly  bounded  by  the  median  line. 
The  tactile  sensibility  was  a  little  obtuse  in  the  left  superior  extremity, 
but  the  sensibility  to  pain  was  exaggerated.  The  muscular  sensibility 
was  also  more  marked  than  in  the  normal  state. 

The  superior  extremities  were  strongly  contracted;  the  forearm  was 
flexed  on  the  arm,  and  the  fingers  were  also  strongly  flexed.  Attempts 
made  to  extend  the  limbs  were  only  partially  successful  and  caused 
pain.  The  contracted  muscles  were  the  seat  of  continuous  spontaneous 
pains,  and  from  time  to  time  sudden  movements  took  place  in  these 
members,  either  spontaneously  or  as  a  consequence  of  reflex  action. 
Neither  of  these  limbs  could  be  moved  by  voluntary  power. 

The  trunk  was  rigid  and  its  muscles  were  painful  to  pressure. 
Pressure  on  the  cervical  region  of  the  skin  also  caused  pain. 

Both  inferior  extremities  were  also  strongly  flexed.  Pressure  on 
the  muscles  caused  pain,  and  there  were  also  darting  pains  through  these 
limbs. 

The  case  was  regarded  as  one  of  hysteria.  The  patient  remained  in 
the  hospital  two  years,  and  left  in  about  the  same  state  as  when  she 
entered.  Subsequently  the  symptoms  almost  entirely  disappeared, 
nothing  remaining  but  a  weakness  of  the  lower  extremities  and  a  slight 
degree  of  contraction  of  the  upper.  But  in  1855  she  had  another  hys- 
terical attack,  and  this  was  followed  by  a  return  of  the  former  con- 
dition. 

In    1856    she    entered   the    S:dpet  Here,   and    in    1862    her    ease   Mas 

studied  by  M.  Charcot.     The  symptoms  were  similar  to  those  which 

1  Cited  by  Bourncvillc,  ''Do  la  contraction  hystSrique  permanente,"  Paris,  i*7'_\  p,  77. 


552  DISEASES   OF   THE   SPINAL   CORD. 

have  been  described,  though  even  more  pronounced.  In  1864  she  died 
during  an  attack  of  erysipelas. 

The  post-mortem  examination  showed  the  essential  lesion  to  consist 
of  sclerosis  of  the  lateral  column  from  the  medulla  oblongata  to  the 
lower  boundary  of  the  lumbar  enlargement.  The  gray  matter  was 
healthy  throughout. 

A  study  of  this  case  shows  that  the  principal  symptoms  of  primary 
symmetrical  lateral  sclerosis  are  as  Tiirck  described  them  in  his  mem- 
oir— paralysis,  contractions,  and  pain  in  the  back  and  limbs.  To  these 
must  also  be  added  the  exaggerated  knee-jerk  and  the  ankle  clonus. 

Causes. — The  causes  of  the  disease  are  probably  similar  to  those 
producing  so  many  other  spinal  affections — cold,  dampness,  over-exer- 
tion, syphilis.     Nothing  very  definite  is  known  on  the  subject. 

Diagnosis. — The  elements  of  the  diagnosis  of  primary  symmetrical 
lateral  sclerosis  of  the  spinal  cord  are  the  presence  of  contractions  with 
paralysis  but  without  atrophy,  and  the  absence  of  any  organic  disease 
of  the  brain  or  superior  part  of  the  cord  (bulb)  which  could  give  rise  to 
the  condition  as  a  secondary  disorder.  It  must,  however,  be  borne  in 
mind  that  contractions  are  the  expression  of  degeneration  of  the  lateral 
pyramidal  tract.  It  is  only  by  attention  to  the  clinical  history  of  the 
case  that  we  can  ascertain  whether  the  lesion  is  primary  or  secondary. 
But  it  must  be  remembered  that  it  is  a  matter  of  the  most  rare  occur- 
rence for  the  motor  tracts  of  both  hemispheres  to  undergo  degenera- 
tion simultaneously,  while  in  the  spinal  cord  it  is  equally  rare  to  find 
the  disease  limited  to  one  lateral  pyramidal  tract  only. 

The  distinction  between  the  disease  in  question  and  progressive 
muscular  atrophy  is  so  clear  as  scarcely  to  require  comment,  and  from 
amyotrophic  lateral  spinal  sclerosis,  the  absence  of  atrophy  and  its  ac- 
companiments, and  of  a  tendency  to  attack  the  nuclei  of  the  bulbar 
nerves,  will  serve  to  make  the  discrimination. 

It  has  more  affinities,  so  far  as  its  symptoms  are  concerned,  with 
chronic  spinal  meningitis,  multiple  spinal  sclerosis,  and  with  tumors 
which,  by  their  pressure  on  the  cord,  may  give  rise  to  very  similar 
phenomena  to  those  exhibited  in  lateral  sclerosis.  I  am  afraid  the 
difficulties  of  making  a  diagnosis  between  it  and  these  affections  are, 
in  the  present  state  of  our  knowledge,  almost  insurmountable.  I  know 
of  no  sure  signs  by  which  the  discrimination  can  be  made. 

Prognosis. — Although  remissions  may  take  place,  the  prospect  of 
an  entire  cure  is  not  very  great.  The  progress  of  the  disease  is,  how- 
ever slow  in  the  majority  of  cases,  and  its  course  may,  I  am  satisfied, 
be  materially  retarded  if  not  altogether  arrested  in  some  cases. 

Morbid  Anatomy  and  Pathology. — Tttrck  was  the  first  to  associate 
sclerosis  of  the  lateral  columns  with  a  definite  set  of  symptoms.  In 
three  of  the  cases  of  the  twelve  on  which  his  memoir  is  based  he  found 
these  regions  of  the  cord  the  seat  of  symmetrical  sclerosis.    It  has  been 


INFLAMMATION   OF   THE   LATERAL   COLUMNS. 


553 


very  definitely  settled  that  the  lateral  columns  are,  in  embryonic  life, 
anatomically  distinct  from  the  rest  of  the  cord  ;  and,  though  in  the 
process  of  development  this  anatomical  separation  is  apparently  lost, 
pathology  shows  us  that  it  in  reality  exists. 

Charcot,1   in  considering  this  subject,  calls  attention  to  the  fact 
that  transverse  sections  of  the  cord  in  cases  of  primary  symmetrical 


Fig.  G6. 


Fig.  G7. 


Fig.  68. 


Fig.  G9. 


lateral  sclerosis  made  through  the  cervical  enlargement  show  that  the 
alteration  embraces  a  greater  extent  of  the  cord  than  when  any  other 
part  is  affected.  Thus,  when  the  region  in  question  is  the  seat  of  the 
lesion,  the  sclerosis  extends  anteriorly  as  far  as,  and  even  beyond,  the 
external  angle  of  the  anterior  horn,  while  posteriorly  it  almost  en- 
croaches on  the  posterior  tract  of  gray  matter.  On  the  outside  it  is 
always  separated  from  the  cortical  layer  by  a  tract  of  white  tissue 
which  remains  intact. 

In  Fig.  GG  is  represented  a  transverse  section  of  the  cord  made 
through  the  cervical  enlargement,  a  denotes  the  sclerosed  portion  ex- 
tending beyond  the  external  angle  of  the  anterior  tract  of  gray  matter 
reaching  to  the  posterior  tract  behind,  and  separated  from  the  cortex 
by  a  layer  of  unaltered  white  substance. 

In  the  dorsal  region  the  lesion  is  more 
circumscribed,  as  is  seen  from  an  examina- 
tion of  Fig.  GT,  which  represents  a  section 
of  the  cord  through  the  middle  of  that 
part.  In  front  it  scarcely  reaches  the 
posterior  boundary  of  the  anterior  tract 
of  gray  matter.  As  in  the  section  just 
described,  the  sclerosed  portion  does  not 
extend  to  the  cortical  layer  of  the  cord. 

In  the  lumbar  region  the  lesion  is  still 
less  extensive,  occupying  only  about  a  quarter  of  the  area  of  the  lat- 
eral columns.  Unlike  the  lesion  in  the  cervical  and  dorsal  regions,  it 
ton. 'Ins  the  cortical  layer  of  the  cord  (Fig.  68).  The  undegenerated 
white  matter  situated  on  the  periphery  of  the  lateral  pyramidal  tracts 
from  the  lower  dorsal  region  upward  is  the  direct  cerebellar  tract. 
This  tract  is  not  found  in  the  lumbar  region. 

Finally,  in  those  cases  in  which  the  morbid  process  extends  to 
the  medulla  oblongata,  we  find  it   seated  in   the  anterior  pyramids, 

1  Op.  cit.,  p.  220. 


554 


DISEASES   OF   THE   SPINAL   CORD. 


not  in  the  nuclei  of  the  bulbar  nerves,  as  in  cases  of  amyotrophic  lat- 
eral spinal  sclerosis  to  be  presently  considered.  Fig.  09  represents 
a  transverse  section  of  the  medulla  oblongata  through  the  middle 
part  of  the  olivary  bodies  ;  A  A,  the  anterior  pyramids  in  a  state  of 
sclerosis. 

In  primary  symmetrical  lateral  sclerosis  the  initial  stage,  as  in 
other  inflammatory  affections  of  the  spinal  cord,  whether  acute  or 
chronic,  is  probably  congestion.  This  congestion  begins  in  the  axis 
cylinders  of  the  nerve  tubes  and  eventually  becomes  a  chronic  inflam- 
mation. From  the  axis  cylinder  the  inflammation  extends  to  the 
nerve  and  sheath  and  eventually  to  the  connective  tissue,  which 
undergoes  proliferation  and,  by  its  increase  in  volume,  presses  upon  and 
gradually  destroys  the  nerve  tubes.  This  evidently  accounts  for  the 
paresis  which  is  the  initial  symptom  of  the  disease.  As  the  nerve 
fibres  descend  they  are  continually  branching  off  to  connect  with  the 
motor  cells,  in  the  anterior  horn  of  gray  matter.  This  accounts  for 
the  gradual  diminution  in  the  area  of  the  lateral  pyramidal  tracts  as 


Fig.  70. 


pMC. 


Diagrammatic  representation  of  the  connection  between  the  lateral  pyramidal  tract  and  the 
motor  cells  in  the  anterior  horn;  also  the  reflex  fibres.     (Modified  from  Bramwell.) 

pmc,  Posterior  median  column,  or  column  of  Goll.  pec,  Posterior  external  column,  or 
column  of  Burdach,  through  which  a  deep  reflex  fibre  (fi)  passes  to  join  the  motor 
cell  at  3.  8,  A  superficial  reflex  fibre  passing  through  the  posterior  horn  of  gray 
matter  to  join  the  motor  cell  at  2.  / p  t,  Lateral  pyramidal  tract,  from  which  a  motor 
nerve-fibre  (1 )  passes  to  the  motor  cell.  4,  Motor  fibre  to  a  muscle.  5,  Fibre  to 
neighboring  cells.     6,  Fibre  to  motor  cells  in  opposite  horn. 

they  descend.  The  inflammatory  process  is  transmitted  by  these 
fibres  to  the  motor  cells  in  the  anterior  horn  which  are  thereby  kept 
in  a  state  of  continual  irritation. 


INFLAMMATION   OF   THE   LATERAL   COLUMNS.  555 

All  motor  cells  by  constant  vibration  keep  the  imiscles  which  they 
supply  moderately  contracted,  or,  as  it  is  commonly  termed,  "  in  tone." 
This  is  beautifully  demonstrated  in  Bell's  facial  paralysis,  where  one 
side  of  the  face  is  paralyzed.  The  normal  "  tone  "  of  the  paralyzed 
side  having  been  abolished,  the  face  is  drawn  toward  the  sound  si,de. 

When  the  motor  cells  are  in  a  constant  state  of  irritation,  the  nor- 
mal "  tone  "  of  the  muscles  which  they  supply  is  enormously  increased. 
Hence  the  stiffness  and  rigidity  of  the  limbs.  The  exaggerated  knee- 
jerk  and  the  ankle  clonus  are,  in  my  opinion,  both  clue  to  the  irritable 
condition  of  the  motor  nerve-cells.  It  is  claimed  by  most  authors  that 
these  two  symptoms  are  caused  by  the  abolition  of  the  power  of 
transmitting  inhibitory  impulses  through  the  lateral  pyramidal  tracts 
owing  to  their  diseased  condition.  It  is  claimed  that  when  a  healthy 
individual  is  struck  on  the  patellar  tendon  that  he  can  restrain  the 
knee-jerk  if  he  desires  to,  and  that,  in  any  case,  there  is  a  certain 
amount  of  involuntary  restraint  ;  and  that  in  disease  of  the  lateral 
pyramidal  tract  this  power  of  inhibition  is  lost.  This  theory  is  not, 
to  my  mind,  supported  by  evidence.  A  healthy  individual  controls 
the  manifestation  of  the  tendon  reflex  by  contracting  the  flexors  of 
the  leg,  but  not  by  any  mental  influence  directed  against  the  knee- 
jerk  impulse.  As  for  involuntary  inhibition,  if  there  is  such  a  thing, 
its  loss  should  be  manifested  immediately  after  a  cerebral  hemorrhage, 
which,  as  Althaus1  points  out,  is  not  the  case.  The  exaggerated  knee- 
jerk  and  the  ankle  clonus  do  not  appear  until  the  descending  degener- 
ation has  reached  the  lateral  pyramidal  tract. 

On  the  other  hand,  it  is  not  difficult  to  believe  that  irritable  nerve- 
cells  will  send  out  irritable  impulses  under  stimulation.  Hence,  if  a 
blow  is  struck  on  the  patellar  tendon  of  an  individual  suffering  from 
sclerosis  of  the  lateral  columns  of  the  cord,  and  in  whom  the  motor 
cells  in  the  anterior  horn  must  necessarily  be  in  a  constant  state' 
of  irritation,  and  the  sensory  impulse  from  the  blow  reaches  these 
cells,  an  irritable  motor  impulse  will  result  and  an  exaggerated  knee- 
jerk  will  necessarily  follow.      (Sec  Fig.  ?().) 

The  ankle  clonus  is  the  exaggerated  reflex  of  the  gastrocnemius. 

Treatment. — In  the  early  period  of  the  disease  large  doses  of  ergot 
will  rarely  fail  to  be  of  service.  1  hare  several  time-  succeeded  in 
relieving  the  paralysis  and  arresting  the  spasms  of  the  limbs  in  cases 
presenting  all  the  initial  phenomena  of  lateral  sclerosis  by  the  persistent 
and  free  use  of  this  remedy.  Hut  t<>  be  efficacious  it  must  lie  given  in 
the  very  firsl  stage,  before  the  paralysis  becomes  extreme,  or  perma- 
nent contractions  arc  present.  A  drachm  of  the  fluid  extract  three 
times  a  day  is  the  smallest  dose  likely  to  prove  efficacious. 

It'  there  is  reason  to  suspect  the  influence  of  syphilis  in  producing 
the  disease,  the  iodide  of  potassium  in  large  and  gradually-increasing 
1  "Sclerosis  of  the  Spinal  Cord." 


556  DISEASES   OF   THE   SPINAL   CORD. 

doses  should  be  administered.  Charcot  and  Gombault '  have  proved 
the  existence  of  disseminated  sclerosis  of  the  cord  in  a  woman  affected 
with  syphilis,  and  there  is  of  course  reason  to  believe  that  the  diffused 
form  such  as  that  now  under  consideration  may  have  a  like  origin. 

In  such  cases  mercury  may  also  be  given,  preferably  in  the  form 
of  the  bichloride,  with  the  iodide  of  potassium. 

Later,  no  treatment  is,  so  far  as  we  know,  calculated  to  materially 
arrest  the  progress  of  the  disease.  Nitrate  of  silver  and  cod-liver  oil 
have  also  occasionally  improved  the  strength  of  the  patient  and  less- 
ened the  rigidity  of  the  contractions,  but  only  for  a  short  time  ;  and 
the  primary  uninterrupted  galvanic  current  to  the  spinal  column  and 
the  contracted  muscles  has  also  proved  serviceable  in  the  same  way 
and  to  a  like  extent. 

Up  to  quite  a  recent  period  I  had  never  derived  any  benefit  in 
cases  of  lateral  sclerosis  from  counter-irritation,  but  I  am  disposed  to 
think  from  some  late  experience  that  the  actual  cautery,  applied  on 
each  side  of  the  spinous  processes  throughout  the  entire  length  of  the 
vertebral  column  and  frequently  repeated,  is  useful. 

For  the  relief  of  pain,  morphia  may  be  administered,  or  what  is,  I 
think,  preferable,  as  it  does  not  appear  to  be  an  excitant  of  the  cord, 
codeine.     Half  a  grain  or  more  may  be  given  as  required. 

Hypodermic  injections  of  atropia,  beginning  with  the  one  hundred 
and  twentieth  of  a  grain  and  increasing  gradually,  are  beneficial  in 
mitigating  the  spasms  of  the  muscles. 

VI. 

INFLAMMATION  OF  THE  LATERAL  COLUMNS  OF  THE  SPINAL  CORD  AND 
OF  THE  ANTERIOR  TRACT  OF  GRAY  MATTER  (AMYOTROPHIC  LAT- 
ERAL  SPINAL   SCLEROSIS. 

For  the  recognition  of  this  affection  and  the  patho-anatomical  data 
relative  to  its  identity,  we  are  indebted  to  Charcot,  who,  writh  his  cus- 
tomary ability,  has  presented  a  mass  of  facts  abundantly  sustaining 
his  views  in  regard  to  its  autonomy.  Cases  exhibiting  the  phenomena 
of  amyotrophic  lateral  spinal  sclerosis  were  noticed,  and  their  details 
published  before  he  enunciated  his  doctrines  on  the  subject ;  but  the 
relations  of  the  lesions  to  the  symptoms  were  not  known  previous  to 
his  observations. 

Symptoms. — The  first  symptom  to  make  its  appearance  in  the 
affection  under  notice  is  paralysis,  which  occurs  ordinarily  gradually, 
advances  steadily,  and  may  involve  at  the  same  time  one  or  more  of 
the  limbs.     Generally  atrophy  ensues  soon  after  the  appearance  of  the 

'  "  Note  sur  une  caa  des  16sioos  dissemindes  des  centres  nerveux  observees  chez  une 
femrae  syphilitique,"  Archives  de  physiologic,  18Y3,  p.  143. 


AMYOTROPHIC   LATERAL   SPIXAL   SCLEROSIS.  557 

paralysis,  and,  as  in  infantile  spinal  paralysis,  and  the  spinal  paralysis 
of  adults,  involves  whole  groups  of  muscles  at  once — not  the  individ- 
ual muscles  in  succession,  as  in  progressive  muscular  atrophy. 

After  a  time  the  morbid  process  in  its  ascending  course  reaches 
the  medulla  oblongata,  and,  thus  implicating  the  nuclei  of  the  facial, 
>1  iual  accessory,  hypoglossal,  and  pneumogastric  nerves,  especially  the 
two  latter,  causes  atrophy  of  the  tongue,  and  many  of  the  other 
symptoms  met  with  in  progressive  muscular  atrophy  affecting  these 
centres.  Finally,  death  takes  place  from  interruption  to  the  proc< 
of  respiration  and  circulation. 

The  muscles  which  are  the  seat  of  atrophy  are  subject,  as  in  pro- 
gressive muscular  atrophy,  to  fibrillary  contractions,  which,  however, 
as  in  the  last-named  affection,  precede  the  atrophy,  and  advance  and 
attain  their  greatest  development  pari  passu  with  the  wasting. 

The  electrical  reactions  of  the  affected  muscles  show  both  qualita- 
tive and  quantitative  degenerations.  As  the  atrophy  progresses  the 
muscl«<  respond  less  and  less  to  the  faradaic  current,  and  finally  cease 
to  respond  to  it  at  all.  At  first  there  is  a  gradual  decline  of  the  gal- 
vanic contraction,  but  at  the  expiration  of  a  few  weeks'  time  it  will 
be  observed  that  moderately  strong  currents  produce  good  contrac- 
tion- :  but  it  will  also  be  noticed  that  the  anodal  closure  contraction 
equals  or  excels  the  cathodal  closure  contraction.  In  other  words,  the 
polar  reactions  of  degeneration  (see  page  28)  are  present. 

But  the  feature  which  is  most  characteristic  of  amyotrophic  lateral 
spinal  sclerosis  is  the  permanent  contractions  of  which  the  affected 
limbs  are  the  seat.  These,  though  in  part  due,  as  Charcot '  says,  to  the 
paralysis  of  certain  antagonistic  muscles,  are  mainly  caused  b}-  spas- 
modic contractions  of  the  non-paralyzed  or  partially  paralyzed  muscles, 
so  that  the  joints  are  rigidly  flexed.  The  position  assumed  when  the 
forearm  and  hand  are  the  seat  of  this  deformation,  is  shown  in  Fig.  71. 
The  fingers  are  Hexed  upon  the  palm,  the  thumb  adducted,  and  the  hand 
Btrongly  bent  upon  the  arm. 

In  the  case  of  a  gentleman  who  came  under  my  observation  in  Sep- 
tember, 1874,  the  position  of  the  left  hand  was  very  similar  to  that 
shown  in  the  figure.  The  arm  was  semiflexed,  and  the  whole  member 
held  firmly  against  the  walls  of  the  chest,  by  the  action  of  the  peotoral 
and  latissimus  dorsi  muscles.  Any  attempt  to  overcome  the  contrac- 
tions was  strongly  resisted  by  the  muscles,  and  caused  very  consider- 
able pain.  The  atrophy  of  the  paralyzed  muscles  was  well  marked, 
and  fibrillary  contractions  were  easily  excited,  even  if  hot  present 
when  the  inspection  was  made. 

In  this  case  the  disease  had  appeared  suddenly  six  months  previous- 
ly, after  exposure  subsequent  to  a  debauch.     The  upper  extremities 

1  "  Lee  >ns     BUI    lei     inala'lics    ilu     >_\~n''inc     uci  vru\,"    :: I'.i- dcule,     I'.iri-,     1 

p.  284. 


558 


DISEASES   OF   THE   SriNAL   CORD. 


only  were  affected,  but  there  was,  even  when  I  saw  the  patient,  a  little 
restraint  in  the  movements  of  the  tongue.  I  did  not  see  him  again, 
but  I  heard  that  death  had  ensued  from  dysentery  three  months  after 


Fig 


his  visit  to  me.  I  also  learned  that  his  tongue  had  become  atrophied, 
and  that  there  was  difficulty  of  swallowing. 

In  another  case  the  contracted  muscles  were  the  pectorals,  and  the 
left  arm  was,  in  consequence,  drawn  strongly  across  the  front  of  the 
chest.  This  patient,  a  man  forty  years  of  age,  was  paralyzed  in  both 
upper  extremities,  but  the  contraction,  when  I  first  saw  him,  was  limited, 
as  stated,  to  the  pectoral  muscles.  He  visited  me  again  about  six  months 
afterward,  and  then  the  right  upper  extremity  was  also  contracted 
throughout  its  extent.  The  fingers  were  bent  on  the  palm  to  such  a 
degree  that  they  could  not  be  opened  by  any  force  which  it  was  safe 
to  apply,  and  pressed  so  strongly  on  the  palm  as  to  cause  pain.  If  the 
nails  were  allowed  to  project  beyond  the  ends  of  the  fingers — and  it 
was  very  difficult  to  keep  them  short — they  entered  into  the  skin  and 
caused  painful  sores.  The  hand  was  flexed  on  the  wrist,  the  elbow  half 
bent,  and  the  arm  was  held  firmly  against  the  side  of  the  chest.  i\t 
the  time  of  the  first  visit  of  this  patient  there  was  no  evidence  of  any 
alteration  of  the  medulla  oblongata,  but  at  the  scccna  visit  there  wTere 
several  indications  of  incipient  bulbar  paralysis.  Deglutition  was  effect- 
ed with  difficulty,  the  tongue  could  not  be  carried  to  the  roof  of  the 
mouth,  was  protruded  only  slightly  upon  great  effort  being  made,  and 
was  the  seat  of  constant  fibrillary  contractions. 

The  atrophy  of  the  paralyzed  muscles  was  well  marked,  and  fibril- 
lations were  so  strong  as  to  be  a  source  of  great  discomfort.  The 
lower  extremities  were  not  then  involved,  and  the  bladder  and  sphinc- 
ters were  intact.  I  have  not  seen  the  patient  since — now  about  seven 
months — and  am  ignorant  of  the  subsequent  course  of  the  disease. 


AMYOTROPHIC   LATERAL   SPIXAL   SCLEROSIS.  559 

The  contractions  are  not  always  similar,  either  in  extent  or  strength, 
in  the  corresponding  limbs,  and  they  may  for  a  time,  especially  in  the 
early  stages  of  the  disease,  disappear.  But  they  reappear  later,  and 
tend  to  become  more  and  more  rigid  as  the  affection  advances  ;  still, 
in  the  most  extreme  period  of  the  malady,  as  the  atrophy  becomes  pro- 
nounced, they  disappear  wholly  or  in  part,  there  being  little  if  any 
muscle  left  to  maintain  the  contraction. 

Another  feature  is  a  spasmodic  extension  of  the  paralyzed  limbs, 
especially  the  lower,  which  is  most  strongly  marked  as  the  patient  lies 
in  bed  ;  or  the  members  may  be  involuntarily  flexed  and  remain  in  that 
condition  for  several  minutes  or  longer.  These  movements  are  not  ordi- 
narily accompanied  with  pain,  as  are  those  of  spinal  meningitis,  which 
in  many  respects  they  resemble. 

The  patient  very  generally  experiences  severe  pains  in  the  affected 
limbs,  which  are  aggravated  or  excited  by  pressure  or  traction  in  the 
muscles.  Numbness  is  also  usually  present  to  a  greater  or  less  degree, 
but  there  is  never  complete  anaesthesia. 

A  peculiar  kind  of  tremor  is  sometimes  seen  in  the  limbs,  the  mus- 
cles of  which  are  partially  paralyzed  and  atrophied.  This  is  in  reality 
not  so  much  a  tremor  as  it  is  a  more  extensive  movement,  resembling 
that  which  is  present  in  some  old  cases  of  hemiplegia  from  cerebral 
haemorrhage.  It  is  only,  like  that,  manifested  when  voluntary  move- 
ments are  attempted. 

As  previously  stated,  the  disease,  unless  death  ensues  from  some  in- 
tercurrent affection,  eventually  extends  to  the  medulla  oblongata.  In 
none  of  my  cases  has  this  circumstance  been  present  to  any  marked 
degree  while  the  patients  were  under  my  observation  ;  but  in  two,  as 
we  have  seen,  there  were  indications  of  such  extension  when  they 
passed  from  under  my  notice.  Charcot  states  it  to  be  an  invariable  se- 
quence, so  far  as  his  observations  extend,  and  he  sums  up  the  subject 
as  follows  :  The  paralysis  of  the  tongue,  inducing  a  difficulty  of  swal- 
lowing and  of  articulation,  may  cause  a  complete  loss  of  the  power  of 
speech.  The  paralyzed  tongue  presents  very  soon,  in  general,  a  cer- 
tain degree  of  atrophy  ;  it  is  shrunken,  wrinkled,  and  agitated  with 
vermicular  movements. 

Tin;  paralysis  of  the  veil  of  the  palate  makes  the  voice  nasal,  and, 
with  the  laryngeal  paralysis,  renders  the  act  of  deglutition  difficult. 

The  orbicularis  oris  being  paralyzed,  an  alteration  in  the  form  of 
the  countenance  takes  place.  The  mouth  is  considerably  enlarged 
transversely,  through  the  predominance  of  the  action  of  the  muscles 
which  ;ne  not  involved,  The  naso-labial  furrows  are  depressed.  The 
symptoms  </\\o  to  the  physiognomy  a  sad  expression.  The  mouth,  es- 
pecially alter  laughing  or  weeping,  remains  for  a  long  time  half  open, 
and  allows  the  viscid  saliva  to  How  oontinually. 

Finally,  by  reason  of  the   implication  of  the  pneumogastrics,  gravo 


560  DISEASES  OF   THE   SPINAL   CORD. 

troubles  of  the  respiration  and  circulation  supervene,  and  cause  the 
death  of  the  patient,  already  weakened  by  insufficient  nourishment. 

In  some  cases  there  are  variations  from  the  ordinary  course  of  the 
disease.  It  has  begun  in  the  lower  extremities  instead  of  the  upper, 
and  again  has  been  restricted  in  its  domain  for  a  long  time  to  a  single 
limb  or  to  one  side  of  the  body.  In  two  cases,  according  to  Charcot, 
it  has  begun  with  the  bulbar  symptoms,  which  in  general  appear  only 
at  the  end.  In  regard  to  such  instances  as  these  last,  there  is  doubt  of 
their  being  examples  of  amyotrophic  lateral  sclerosis. 

Causes. — Exposure  to  cold  and  dampness  appears  to  be  the  most 
efficient  exciting  cause  of  the  disease.  In  one  of  Charcot's '  cases,  the 
patient,  an  itinerant  showman,  was  exposed  during  a  journey  to  cold 
and  rain.  The  following  morning  he  was  taken  with  a  chill,  which  was 
repeated  thirty-six  hours  afterward,  and  then  he  was  seized  with  pains 
along  the  course  of  the  nerves,  and  in  the  joints  mainly  of  the  upper 
extremities.  Fibrillations  accompanied  them,  and  paralysis  and  atrophy 
soon  followed.  In  the  case  occurring  in  my  own  experience,  the  patient 
became  intoxicated,  and  wandering  into  the  Central  Park,  lay  all  night 
on  wet  grass,  exposed  to  a  cold,  drizzling  rain.  In  the  morning  he  was 
arrested  and  taken  to  the  police  court,  and  sent  to  Blackwell's  Island  for 
ten  days.  On  his  way  up,  he  was  subjected  to  the  influence  of  a  cold  wind, 
which,  blowing  on  his  wet  clothes,  chilled  him  more  and  more.  The 
following  morning  he  was  discharged,  his  friends  having  ascertained 
his  situation  and  paid  his  fine.  But  he  already  felt  a  degree  of  weak- 
ness in  his  arms,  and  in  the  course  of  a  week  they  were  to  a  great 
extent  deprived  of  motor  power.  Fibrillary  contractions  were  present 
from  the  first,  but  there  was  no  pain  anywhere. 

In  the  majority  of  cases  no  cause  can  reasonably  be  assigned.  There 
appears  to  be  no  hereditary  influence  to  the  disease. 

Diagnosis. — The  diagnosis  of  amyotrophic  lateral  spinal  sclerosis 
presents  many  features  of  interest.  A  consideration  of  the  essential 
phenomena  shows  that  they  are  as  follows  : 

1.  Paralysis  occurring  in  symmetrical  parts  of  the  body,  unaccom- 
panied by  anaesthesia. 

2.  Atrophy  following  the  -paralysis,  and  attacking  masses  of  mus- 
cles. 

3.  Spasmodic  rigidity,  eventually  leading  to  permanent  contrac- 
tions, lasting  up  to  the  last  stage  of  the  disease. 

4.  Extension  of  the  affection  to  the  lower  extremities,  and  the  su- 
pervention of  intermittent  and  tonic  contractions  or  rigidity. 

5.  The  implication  of  the  medulla  oblongata,  and  death  in  the 
course  of  two  or  three  years. 

Thus,  we  see  that  the  affinities  of  amyotrophic  lateral  spinal  sclero- 
sis are  with  spinal  paralysis  of  adults  and  progressive  musoular  atrophy, 
'  "  Deux  cas  d'atrophie  musculaire  progressive,"  Archives  de physiologic,  1869,  p.  687. 


AMYOTROPHIC   LATERAL   SPINAL  SCLEROSIS.  561 

with  which  latter  disease  it  was  confounded  by  Dumesuil,1  Charcot,2 
and  others,  up  to  quite  a  late  period. 

But  the  differences  between  it  and  both  these  diseases  are  suffi- 
ciently striking  to  prevent  much  danger  of  confounding  them.  Thus 
from  spinal  paralysis  of  adults  it  is  discriminated  by  the  facts  that 
reflex  excitability  is  not  impaired,  nor  the  electric  excitability  of  the 
muscle  diminished,  as  in  the  former  affection  ;  that  the  atrophy  is  more 
profound  and  constant;  that  fibrillations  are  present,  and  especially  by 
the  existence  of  the  spasmodic  contractions  of  the  limbs  which  form  so 
prominent  a  feature  of  amyotrophic  lateral  spinal  sclerosis. 

From  progressive  muscular  atrophy  the  distinction  can  be  readily 
made  out.  In  the  facts  that  paralysis  precedes  the  atrophy,  that  the 
wasting  takes  place  in  groups  of  muscles,  and  that  spasmodic  contrac- 
tions occur  in  amyotrophic  lateral  spinal  sclerosis  ;  while  in  progres- 
sive muscular  atrophy  the  paralysis  is  consequent  on  the  wasting,  the 
muscles  shrink  singly  and  irregularly,  fibre  by  fibre,  and  spasmodic  con- 
tractions do  not  occur,  we  have  sufficiently  precise  diagnostic  marks  of 
differences  between  the  two  affections. 

Prognosis. — There  is  no  case  of  cure  on  record.  The  course  of  the 
disease  is  progressively  onward.  In  the  majority  of  cases  the  fatal  ter- 
mination occurs  within  two  years;  occasionally,  it  is  deferred  for  a  few 
months  longer. 

Morbid  Anatomy  and  Pathology. — As  I  have  said,  amyotrophic 

lateral  spinal  sclerosis  has,  until  quite  lately,  been  regarded  as,  at  most, 
an  eccentric  form  of  progressive  muscular  atrophy.  It  is  among  the 
reports  of  cases  of  this  affection,  therefore,  that  we  must  search  for 
early  data  relative  to  the  morbid  anatomy  of  the  disease  under  consid- 
eration. 

Dumesnil,'  in  1867,  reported  the  details  of  five  cases  of  spinal  disease 
under  the  name  of  progressive  muscular  atrophy,  two  of  which  were, 
undoubtedly,  instances  of  amyotrophic  lateral  spinal  sclerosis.  In  both 
of  these,  symptoms  such  as  have  been  described  were  present,  and,  on 
post-mortem  examination,  lesions  of  the  lateral  columns  and  anterior 
horns  of  gray  matter  were  found  to  exist. 

Charcot  and  Joffroy  *  have  given  with  fullness  of  detail  the  particu- 
lars of  two  cases  of  amyotrophic  lateral  spinal  paralysis,  in  which  the 
post-mortem  examination  was  very  thorough. 

1  "  Nouveaux  faita  relatifs  a  la  pathogenie  de  Patrophie  musculaire  progressive,'' 
Gazette  hebdomaduire,  Nos.  27,  20,  30,  1867. 

9  "Deux  caa  d'atropHie  musculaire  progressive  avec  16sions  de  la  substance  grise  et 
des  faiseaux  antero-lateraux  de  la  moelle  epinidre,"  Archives  de phyriolopie,  No.  4, 

•"Nouveaux  raits  relatifs  a  la  pathogenie  de  ['atrophic  musculaire  progressive,* 
Gazttv  hebdomadaire,  Nos.  ^7,  89,  SO,  1887. 

*  "  Deux  oas  d'atrophie  musculaire  progressive  avec  lesions  de  la  Bubetance  grise  et 
des  faiseaux  anteio-lateraux  de  la  moelle  opiuicn-,''  Arvhivet  de phyiioloffU,  18«>7. 

:;; 


562  DISEASES   OF   THE   SPINAL   CORD. 

The  first  of  these  is  reported  as  a  case  of  progressive  muscular 
atrophy,  especially  marked  in  the  upper  extremities,  with  atrophy  of 
the  muscles  of  the  tongue  and  of  the  orbicularis  oris  and  paralysis  with 
rigidity  of  the  inferior  limbs.  On  post-mortem  examination  the  nerve- 
cells  of  the  anterior  horns  in  the  cervical  and  dorsal  regions  were  found 
atrophied,  while  many  had  disappeared.  In  the  bulb  there  were  atrophy 
and  disappearance  of  the  nerve-cells,  constituting  the  nucleus  of  the 
hypoglossal.  The  anterior  roots  of  the  spinal  nerves  and  the  roots  of 
the  hypoglossal  and  the  facial  were  also  atrophied.  In  addition,  there 
was  symmetrical  diffused  sclerosis  of  the  lateral  columns.  In  this  case 
the  bulb  was  affected  after  the  lower  parts  of  the  cord,  and  the  lesion 
of  the  nuclei  of  the  hypoglossal  and  facial  was  of  such  a  nature  as  to 
cause  atrophy  of  the  tongue  and  orbicularis-oris  muscle.  The  instance 
was,  therefore,  of  a  typical  character. 

The  second  case  has  already  been  cited  under  another  head  of  this 
chapter.  It  is  entitled — Progressive  muscular  atrophy  especially  mani- 
fested in  the  upper  extremities;  acute  pains  in  the  limbs  coming  on  in 
paroxysms  ;  anaesthesia  in  certain  parts  of  the  body  ;  paralysis  with 
rigidity  of  the  inferior  extremities;  lesions  of  the  nerve-cells  of  the. 
anterior  horns  of  gray  matter;  centres  of  gray  degeneration  in  the 
posterior  horns;  symmetrical  diffused  sclerosis  of  the  lateral  columns  ; 
considerable  thickening  of  the  spinal  dura  mater  and  pia  mater  of  the 
cervical  enlargement. 

This  case  was  not  an  uncomplicated  one,  but  still  the  essential 
lesions  of  the  anterior  horns  of  gray  matter  and  of  the  lateral  columns 
are  perceived  to  have  been  present. 

Gombault1  reports  the  case  of  a  woman  in  whom  the  symptoms 
were  not  developed  with  any  suddenness,  but  in  whom  there  gradually 
supervened  loss  of  power  with  atrophy  and  contractions  in  the  upper 
extremities,  then  paralysis  with  atrophy  in  the  lower  limbs,  and  finally 
atrophy  of  the  muscles  of  the  tongue  and  lips,  with  difficulty  of  swal- 
lowing, and  the  other  symptoms  of  glosso-labio-laryngeal  paralysis. 
Post-mortem  examination  showed  the  lateral  columns  to  be  symmetri 
cally  sclerosed,  and  in  the  anterior  horns  of  gray  matter  symmetrical 
lesions,  exactly  limited  to  this  region,  and  consisting  of  atrophy,  pig- 
mentary degeneration,  and  disappearance  of  the  nerve-cells.  In  the 
bulb,  the  nuclei  of  origin  of  the  bulbar  nerves  were  similarly  altered. 

It  is  perceived,  therefore,  that  in  amyotrophic  lateral  spinal  sclero- 
sis the  essential  lesions  are  seated  symmetrically  in  the  lateral  columns 
and  in  the  anterior  horns  of  gray  matter,  and  that  when  the  morbid 
process  extends — as  it  always  does,  if  the  patient  does  not  die  in  the 
mean  time  of  some  intercurrent  affection — to  the  medulla  oblongata,  it 

1  "  Sclerose  svni6trique  des  cordons  lateraux  de  la  moelle  et  des  pyramides  anterieurs 
dans  la  bulbe ;  atropbie  des  cellules  des  cornes  anterieures  de  la  moelle;  atropine  nius> 
culaire  progressive;  paralysie  glosso-laryngee,"  Arc/lives  de  physiologic,  1872,  p.  589. 


AMYOTROPHIC   LATERAL   SPINAL   SCLEROSIS. 


563 


invades  the  nuclei  of  origin  of  the  nerves  which  are  affected  in  glosso- 
labio-laryngeal  paralysis.      The  accompanying  woodcut  from   Charcot 


represents  a  section  of  the  bulb  made  at  the  level  of  the  middle  part 
of  the  nucleus  of  the  hypoglossal  ;  a  b  to  the  right  of  the  imaginary 
line  R  R'  represents  the  normal  condition  ;  <7,  the  nucleus  of  the  hypo- 
glossal composed  of  about  thirty  multipolar  ganglion-cells;  e,  a  vessel 
circumscribing  the  nucleus;  c,  the  floor  of  the  fourth  ventricle;  d,  the 
fasciculus  teres  ;  b,  nucleus  of  the  pneumogastric.  On  the  left  the 
letters  a'  b\  etc.,  represent  the  corresponding  parts  in  a  case  of  amyo- 
trophic lateral  spinal  sclerosis.  It  is  perceived  that  only  five  or  six 
cells  exist  in  the  nucleus  of  the  hypoglossal.  The  nucleus  of  the  pneu- 
mogastric  is,  on  the  contrary,  normal. 

Now,  it  appears  to  me  that  M.  Charcot  is  wrong  in  considering,  as 
he  apparentlv  does,  every  case  of  glosso-labio-laryngeal  paralysis  ac- 
oompanied  by  progressive  muscular  atrophy  of  the  muscles  lower 
down,  as  one  of  primary  amyotrophic  lateral  spinal  sclerosis. 

Those  cases  of  glosso-labio-laryngeal  paralysis  which,  at  a  later 
period,  exhibil  the  phenomena  of  progressive  muscular  atrophy  in  the 
sles  of  the  upper  extremities  and  of  other  parts  of  the  body  are.  in 
my  opinion,  not  cases  in  which  there  is  primitive  lesion  of  the  lateral 
columns,  bu<  examples  of  secondary  degeneration  of  the  cord,  I 
produced  aa  a  o  tnsequence  of  the  superior  lesion, 

The  case  reported  by  Dr.  Hun,'  <>!'  Albany,  is  quoted  by  Charcol  '  as 
an  instance  of  amyol  rophic  lateral  spinal  sclerosis,  but,  according  t"  the 

1  "Labio-Gloeso  Laryngeal  Paralysis,"  American  Journal  of  fruanity,  1871,  p.  194. 
'  "  Leijons  sur  k-s  maladies  da  Byste oerveux,"  Paris,  1874,  p.  229 


564  DISEASES  OF  THE  SPINAL  CORD. 

view  above  expressed,  it  was  in  reality  a  case  of  glosso-labio-laryngeal 
paralysis  with  secondary  degeneration  of  the  spinal  cord.  The  patient, 
a  man  aged  fifty eignt,  first  noticed  that  the  saliva  dribbled  from  his 
mouth  when  speaking  or  writing.  Shortly  afterward  he  was  conscious 
of  a  difficulty  in  the  pronunciation  of  words,  and  then  there  were  evi- 
dent hesitation  and  defect  in  the  articulation  of  certain  words,  and  his 
voice  became  nasal. 

A  year  afterward  there  were  complete  loss  of  speech,  difficulty  of 
deglutition — any  effort  at  swallowing  being  attended  with  paroxysms  of 
coughing  and  suffocation — and  paralysis  of  the  tongue,  which  could  only 
be  protruded  a  quarter  of  an  inch  beyond  the  edge  of  the  teeth.  There 
was  partial  loss  of  motion  in  both  arms,  but  no  atrophy. 

A  month  subsequently  it  was  noticed  that  he  dragged  his  feet  a 
little,  but  he  could  still  walk  alone  for  a  considerable  distance.  The  pa- 
ralysis advanced  until  he  was  unable  to  walk,  and  the  difficulty  of  deglu- 
tition increased. 

When  seen  by  Dr.  Hun,  January  4,  1871,  "  he  was  sitting  in  a 
chair  propped  up  by  pillows,  being  unable  to  lie  down  on  account  of 
dyspnoea;  complete  loss  of  motion  except  a  little  nodding  of  the  head 
and  a  little  movement  of  the  right  hand;  sight  and  hearing  unimpaired; 
speech  entirely  lost;  mouth  partly  open;  and  lips  immovable,  except  a 
slight  twitching  of  the  left  angle  Of  the  mouth;  cheeks  flaccid;  tongue 
completely  paralyzed  and  lying  on  the  floor  of  the  mouth;  respiration 
feeble,  and  occasional  coughing  ;  pulse  90  per  minute  and  regular  ; 
both  arms  paralyzed  and  slightly  flexed,  and  attempts  to  straighten  the 
fingers  caused  pain;  lower  extremities  completely  paralyzed,  and  feet 
and  ankles  cedematous  ;  defecation  natural  ;  micturition  slow  and  fre- 
quent; attempts  to  swallow  occasioned  distressing  cough  and  suffoca- 
tion, and  the  aliments  were  often  rejected  through  the  nose. 

"  He  remained  in  this  condition  until  the  afternoon  of  the  same  day, 
when  an  attempt  to  swallow  some  porridge  brought  on  severe  coughing 
and  strangling.  At  seven  o'clock  that  evening  he  died  without  a  strug- 
gle. 

"  Autopsy  twenty  hours  after  death. 

"  External  Appearances. — Rigor  mortis  well  marked.  Body  spare 
but  not  emaciated,  no  very  evident  signs  of  muscular  atrophy. 

"  Head. — Scalp  very  dry.  Skull-cap  removed  with  great  difficulty, 
owing  to  adhesions  of  the  dura  mater,  which  was  torn  in  trying  to  sepa- 
rate it  from  the  bone.  Dura  mater  very  much  thickened.  Arachnoid 
normal  with  considerable  serous  infiltration  of  the  sub-arachnoidean 
connective  tissue.  Pia  mater  much  injected.  The  cerebral  substance, 
both  cortical  and  medullary,  appeared  to  be  of  normal  color  and  consist- 
ency but  exceedingly  hypenemic.  The  following  conditions  of  the 
cranial  nerves  were  found  :  1.  Olfactory  normal;  2.  Optic  normal;  3. 
Motor   oculi  normal  ;  4.  Patheticus  small ;  5.  Trigeminus,  on  the  left 


AMYOTROPHIC  LATERAL  SPINAL  SCLEROSIS.  563 

side  flattened,  gray,  and  softened;  on  the  right  side  larger  and  very  hy- 
peraemic; 6.  Abducens  atrophied  especially  on  the  left  side;  7.  Facial 
atrophied  and  gray  on  both  sides  ;  8.  Auditory  normal  ;  9.  Glossopha- 
ryngeal normal ;  10.  Pneumogastric  atrophied  on  both  sides;  11.  Spinal 
accessory  much  atrophied ;  12.  Hypoglossal  so  much  atrophied  on 
both  sides  as  to  resemble  mere  threads  or  filaments  of  connective  tissue. 
The  corpora  striata  and  optic  thalami  were  normal.  The  cerebellum 
was  very  hyperaemic,  but  otherwise  presented  nothing  unusual.  The 
pons  Varolii  and  medulla  oblongata  appeared  to  be  of  firmer  consistency 
than  usual. 

"  Spinal  Cord. — Spinal  meninges  much  injected.  The  anterior 
spinal  roots  were  atrophied,  especially  on  the  left  side.  Transverse  sec- 
tions of  the  cord  showed  the  anterior  cornua  of  gray  matter,  as  well  as 
the  left  anterior  and  right  lateral  column,  to  be  of  a  dark  rose-color,  as  if 
very  hyperaemic. 

"  Portions  of  the  brain,  cerebellum,  and  spinal  cord  were  immersed  in 
absolute  alcohol,  preparatory  to  making  sections  for  microscopic  exami- 
nation. When  sufficiently  hardened,  thin  sections  were  made,  stained 
with  carmine,  rendered  transparent  with  benzole,  and  mounted  in  bal- 
sam. 

"The  sections  of  the  brain  revealed  nothing  abnormal.  The  sec- 
tions of  the  cerebellum  showed  a  very  hyperaemic  condition  of  the  part, 
and  a  granular  degeneration  of  the  large  ganglionic  cells  forming  the 
middle  layer  of  the  cortical  portion. 

"  Thirty  sections  were  made  at  various  levels  of  the  medulla  oblon- 
gata, involving  the  roots  and  nuclei  of  implantation  of  the  cranial 
nerves,  especially  those  of  the  facial  and  hypoglossal.  Careful  micro- 
scopic examination  of  these  specimens,  with  objectives  varying  from 
fifteen  to  nine  hundred  diameters,  demonstrated  that  the  portion  of 
medulla  forming  the  floor  of  the  fourth  ventricle  was  the  seat  of  several 
pathological  lesions. 

"There  was  a  decided  hypertrophy  or  overgrowth  of  the  connective 
tissue,  which  appeared  to  have  encroached  upon  and  to  some  extent 
replaced  the  several  groups  of  ganglionic  cells  which  form  the  nuclei  of 
implantation  for  the  facial  and  hypoglossal  nerves.  The  individual 
cells  comprising  these  groups  were  separated  from  one  another,  and  in 
many  instances  had  lost  their  stellate  appearance  ;  their  radiating  pro- 
cesses having  been  destroyed,  so  that  each  cell  remained  isolated  and 
disconnected  from  its  neighbors.  These  cells  had  also  undergone  a  de- 
g<  oerative  process,  which  in  many  cases  rendered  them  simply  a  collec- 
tion of  fine  granules,  and  a  deposit  of  brownish-yellow  pigment  had 
taken  place  to  such  an  extent  as  to  give  the  cells  an  appearance  almost 
precisely  similar  to  those  which  are  normally  found  in  the  locus  niger 
of  Soemmering  ;  they  were  fewer  in  number  than  usual  and  diminutive 
in  size. 


566  DISEASES   OF   THE   SPINAL   CORD. 

"  Sections  of  the  cord  made  in  the  cervical,  dorsal,  and  lumbar  re- 
gions, showed  a  sclerosis  with  increase  of  the  connective  tissue  in  the 
anterior  and  lateral  columns,  which  was  most  marked  in  the  left  ante- 
rior and  lateral  columns.  The  multipolar  ganglion  cells,  situated  in  the 
anterior  cornua  of  gray  matter,  were  fewer  in  number  than  usual,  and 
many  of  them  appeared  granular  and  very  much  pigmented." 

As  Dr.  Hun  subsequently  remarks,  there  was  here  "  a  descending 
degeneration  of  the  motor  tracts  of  the  cord  consecutive  to  a  primary 
lesion  situated  in  the  medulla.  This  is  fully  in  accordance  with  the 
views  presented  by  Bouchard  in  his  work  on  secondary  degenerations 
of  the  spinal  cord,  and  accounts  for  the  progressive  paralysis  of  the 
trunk  and  extremities  which  follows  the  original  loss  of  motion  in  the 
lips,  tongue,  and  palate." 

The  cases  cited  by  M.  Charcot  from  Leyden 1  are  similar  in  general 
characteristics. 

To  repeat,  glosso-labio-laryngeal  paralysis  is  a  paralysis  without 
atrophy.  Paralysis  and  atrophy  consequent  to  it  of  other  parts  lower 
down,  are  due  to  secondary  degenerations  of  the  cord.  Amyotrophic 
lateral  spinal  sclerosis  is  a  paralysis  with  atrophy.  It  has  a  tendency 
to  ascend  and  to  involve  the  nuclei  of'  the  bulbar  nerves,  causing  the 
atrophy  of  the  muscles  of  the  lips,  tongue,  and  palate,  and  accompanied 
with  fibrillary  contractions,  which  latter  are  not  phenomena  of  glosso- 
labio-laryngeal  paralysis. 

Such  cases  as  those  of  Hun,  Leyden,  and  others,  as  well  as  several 
which  have  come  under  my  own  experience,  are,  so  far  as  their  lower 
spinal  phenomena  are  concerned,  to  be  classed  not  with  the  protopathic, 
but  the  deuteropathic  spinal  amyotrophies  of  Charcot,  the  secondary 
spinal  degenerations  of  Bouchard,  to  which  attention  will  be  given 
hereafter. 

Even  if  we  adopt  M.  Charcot's  view  that  in  such  cases  there  is  a 
real  atrophy  of  the  tongue,  which  is  concealed  by  the  hyperplasia  of 
the  perimysium,  and  the  deposit  of  fat  between  the  muscular  fibres,  we 
could  not  avoid  perceiving  the  difference  between  such  instances  and 
those  of  true  progressive  muscular  atrophy  attacking  the  tongue,  and 
in  which  there  are  fibrillations,  and  no  interstitial  fat  to  mask  the  ver- 
itable condition. 

The  lesions  of  the  muscles  in  amyotrophic  lateral  spinal  sclerosis  are 
similar  to  those  met  with  in  progressive  muscular  atrophy.  The  peri- 
mysium is  increased  in  quantity  and  the  muscular  fibrillas  undergo  fatty 
degeneration  and  atrophy. 

In  considering  the  relation  of  the  phenomena  to  the  lesion,  the  ques- 
tions to  engage  attention  are  mainly  those  which  have  already  been  suffi- 
ciently dwelt  upon,  when  the  other  affections  characterized  bv  paralysis 
and  atrophy  were  under  notice.     One  symptom,  spasmodic  contraction, 

1  "Ueber  progressive  bulbare  Paralysie,"  Archiv  fur  Psychiatrie,  Band  iL,  S.  iiL 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  567 

a  concomitant  of  primary  symmetrical  spinal  sclerosis,  is,  as  has  been 
pointed  out  when  that  disease  was  under  consideration,  the  direct  con- 
sequence of  the  lesion  of  the  lateral  columns. 

Treatment. — In  regard  to  a  malady  of  so  hopeless  a  character  as 
amyotrophic  lateral  spinal  sclerosis,  there  is  little  or  nothing  to  say 
under  this  head.  We  have  no  means  at  our  command  capable  of 
arresting  the  onward  tendency  of  the  disease. 

VII. 

INFLAMMATION    (SCLEROSIS)     OF    THE     POSTERIOR    ROOT-ZONES    OF    THE 
SPINAL  CORD  (PROGRESSIVE  LOCOMOTOR  ATAXIA),   (TABES  DORSALIs). 

In  the  former  editions  of  this  work  I  described  locomotor  ataxia 
under  the  designation — based  upon  its  patho-anatomy  as  then  under- 
stood— of  posterior  spinal  sclerosis.  The  recent  investigations  of 
Charcot  and  his  pupils  have,  however,  shown  that  the  morbid  process 
which  gives  rise  to  the  remarkable  group  of  symptoms  known  as  loco- 
motor ataxia  is  in  reality  situated  in  the  subdivisions  of  the  posterior 
columns,  lying  between  the  columns  of  Goll  and  the  posterior  horns 
of  gray  matter,  and  called  the  posterior  root-zones.  In  accordance, 
therefore,  with  its  exact  morbid  anatomy,  tabes  dorsalis  should  be 
designated  by  the  term  placed  at  the  head  of  this  section.  But,  for 
convenience,  I  shall  generally  use  the  name  locomotor  ataxia,  and  no 
confusion  can  arise  from  this  course,  so  long  as  we  bear  in  mind  the 
relation  which  it  bears  to  the  more  exact  pathological  designation. 

Although  other  writers,  and  especially  Romberg,1  had  described  a 
disease  answering  to  that  now  generally  known  as  locomotor  ataxia,  we 
are  mainly  indebted  to  Ducbenne a  for  giving  a  full  and  distinct  ac- 
count of  an  affection  which,  before  his  studies,  had  scarcely  attracted 
attention.  Since  then,  the  morbid  anatomy,  the  pathology,  and  the 
symptomatology,  have  been  so  thoroughly  studied  by  Charcot,  Pierret, 
"Wrstphal,  and  others,  whose  labors  will  be  presently  more  specifically 
referred  to,  that  the  disease  in  question  may  be  said,  with  truth,  to  be 
one  of  the  most  thoroughly  understood  in  the  whole  range  of  medical 
science. 

Symptoms. — Locomotor  ataxia  has  no  uniform  set  of  initial  symj> 
toms.  Sometimes  it  begins  with  dull,  heavy  pains  in  the  small  of  the 
back  or  other  part  of  the  spinal  column,  which  are  very  soon  followed 
by  sharp,  electric-like  pains,  which  shoot  down  the  limbs  along  (he 
course  of  the  nerves,  and  which  are  very  generally  taken  by  the  patient 
for  twinges  of  neuralgia  or  rheumatism;  or  it  may  be  first  manifested 

1 "  Lehrbucb  der  Nervenkrankheiten,"  Berlin,  1840;  also,  "Sydenham  Society's 
Translation, "  London,  ]*.">:>. 

,4?Dc  I'ataxie  locomotrice  progressive,"  Archive*  Qtnerale*  de  Afidecine,  1858;  also, 
'*  De  l'olectrisation  localisce,"  Paris.  1801. 


568  DISEASES  OF  THE  SPINAL  CORD. 

by  a  feeling  of  constriction  around  the  body  like  that  which  is  so  com- 
mon in  acute  myelitis. 

Again,  the  first  symptoms  are  cerebral,  and  may  consist  of  attacks 
of  vertigo,  pains  either  in  the  front  or  back  of  the  head,  epileptic  fits, 
disturbances  of  vision,  such  as  diplopia,  ptosis,  and  defective  accom- 
modation. In  this  form  the  pupils  are  contracted  often  to  mere  points, 
or  occasionally  they  will  be  found  to  be,  one  contracted,  and  the  other 
dilated. 

At  other  times  the  stomach  and  bowels  are  disordered  ;  vomiting  is 
frequent,  and  there  may  be  diarrhoea  or  obstinate  constipation.  Or, 
finally,  the  initial  phenomena  may  be  connected  with  the  sensibility, 
giving  rise  to  anaesthesia,  and  the  various  abnormal  sensations  con- 
nected therewith. 

In  whatever  way  it  may  begin,  locomotor  ataxia  is  soon  chiefly 
manifested  by  disorders  of  motility,  but  inquiry  reveals  the  fact  that 
these  are  in  reality  secondary,  being  dependent  upon  the  diminished 
sensibility  which  always  exists.  As  this  is  the  essential  feature  of  the 
disease,  I  propose  to  inquire  into  its  characteristics  at  some  length. 

If  the  lesion,  as  it  usually  does,  exists  in  the  dorso-lumbar  region  of 
the  cord,  the  first  evidences  of  anaesthesia  or  of  perverted  sensibility 
are  noticed  in  the  feet.  A  common  feeling  is  as  if  the  toes  are  too 
large  for  the  shoe,  or  as  if  pieces  of  some  plastic  material  are  between 
them.  Sometimes  there  are  burning  pains  in  the  soles  of  the  feet,  and 
very  generally  "  pins  and  needles  "  and  other  forms  of  numbness.  A 
curious  symptom  is  that,  not  only  is  the  sensibility  lessened,  but  the 
transmission  of  sensitive  impressions  to  the  brain  does  not  take  place 
with  the  normal  degree  of  activity.  I  have  noticed  this  phenomenon  in 
rather  more  than  half  the  cases  that  have  come  under  my  observation. 
In  a  lady,  now  a  patient,  a  pin  stuck  into  the  calf  of  the  leg  is  not  felt 
for  fourteen  seconds  on  the  right  side  and  sixteen  on  the  left.  In  a 
patient  with  posterior  spinal  sclerosis,  under  treatment  in  the  New 
York  State  Hospital  for  Diseases  of  the  Nervous  System,  if  the  feet  were 
put  into  hot  water  the  sensation  was  not  felt  for  almost  three  minutes. 
As  he  said,  "  My  feet  might  be  scalded  till  the  flesh  dropped  off  and  I 
would  not  know  it  till  the  mischief  was  done.  Then  I  should  feel  it 
sharply."  The  explanation  of  this  symptom  is  to  be  found  in  the  fact 
that  the  conducting  power  of  the  posterior  columns  is  lessened  by  the 
lesion,  and  hence  the  brain  does  not  receive  in  the  usual  time  the  im- 
pressions made  upon  the  nerves. 

The  ability  to  feel  pain  is  therefore  diminished,  but  there  is,  besides, 
a  marked  abatement  of  the  tactile  sensibility.  The  extent  of  this  can 
only  be  accurately  measured  by  the  aesthesiometer.  When  this  instru- 
ment is  used,  we  find  that  the  two  points  can  be  widely  separated  and 
a  single  impression  only  be  felt  on  parts  of  the  body  which  in  the  nor- 
mal condition  would  give  the  sensation  of  two  points  at  a  much  less 


PROGRESSIVE   LOCOMOTOR  ATAXIA.  569 

distance  apart.  A  gentleman  from  Virginia  consulted  me  recently,  in 
whom  I  diagnosticated  locomotor  ataxia,  and  who,  instead  of  being  able 
to  perceive  the  two  points  with  the  end  of  the  index-finger,  when  the 
twelfth  of  an  inch  apart,  could  feel  but  one  point,  though  the  two  were 
separated  to  the  extent  of  an  inch  and  a  half.  Sometimes,  even  in  the 
early  stages  of  the  disease,  the  loss  of  sensibility  is  so  great  that  the 
patient  hardly  feels  the  points  at  all. 

This  loss  of  sensibility  gives  rise  to  some  curious  sensations,  espe- 
cially in  the  soles  of  the  feet.  These  are  usually  such  as  might  be  pro- 
duced by  the  interposition  of  some  substance  between  the  foot  and  the 
shoe,  or  between  the  shoe  and  the  ground.  One  patient  feels  as  if  he 
has  cushions  on  the  soles  of  his  feet,  another  as  if  bladders  of  air  are 
interposed,  another  as  if  he  is  constantly  treading  on  sticks,  or,  if  riding 
in  an  omnibus,  as  if  the  hem  of  a  lady's  dress  had  got  under  his  feet, 
and  one  a  short  time  since  described  the  sensation  to  me  as  being  like 
that  which  he  thought  he  would  feel  if  his  feet  had  been  dipped  into 
tar,  and  then  into  sand. 

In  some -cases  the  ability  to  distinguish  differences  of  temperature, 
or  to  appreciate  the  sensations  produced  by  the  application  of  hot  or 
cold  bodies  to  the  skin  of  the  affected  parts,  remains,  but  this  is  not,  as 
some  authors  assert,  a  constant  phenomenon,  for  in  the  majority  of 
cases  the  sensations  produced  by  heat  or  cold  are  just  as  unappreci- 
able  as  those  caused  by  any  means  capable  of  giving  rise  to  sensitive 
impressions. 

But  the  symptoms  by  which  locomotor  ataxia  is  recognized  most 
readily  are  those  which  relate  to  motility,  and  the  phenomena  often 
make  their  appearance  at  a  very  early  stage  of  the  affection.  At 
that  time  there  is  no  loss  of  motor  power,  but  there  is  an  inability 
to  coordinate  the  muscles — to  bring  them  to  harmonious  action,  and 
thus  to  execute  with  precision  the  various  voluntary  movements.  Thus, 
in  the  act  of  standing,  a  great  many  muscles  are  simultaneously  made  to 
contract,  and  each  one  to  just  that  necessary  degree  which  is  essential 
to  maintain  the  body  in  the  erect  posture.  Very  often  the  first 
evidence  of  any  motor  trouble  is  experienced  in  regard  to  this  faculty 
of  standing.  This  impediment  is,  however,  not  one  of  paralysis,  for,  if 
the  patient  looks  at  his  feet,  he  has  no  more  trouble  in  standing  alone 
than  a  perfectly  sound  man. 

A  gentleman  connected  with  the  city  government  of  Brooklyn  con- 
sulted me  a  short  time  since  for  an  affection  which  was  very  evidently 
locomotor  ataxia.  The  first  indication  of  disease,  as  he  informed  me, 
was  that  it  had  been  his  habit,  while  at  his  morning  ablutions,  to  shut 
his  eyes,  and  he  had  noticed,  about  two  mont lis  previously,  that  when 
he  did  so  he  could  not  maintain  his  equilibrium.  When  he  visited  me 
he  was  unable  to  stand  with  his  eyes  shut,  and  his  gait  was  perfectly 
characteristic  of  locomotor  ataxia. 


570  DISEASES   OF  THE   SPINAL   CORD. 

Before  the  locomotion  of  the  patient  becomes  obviously  affected,  ho 
experiences  inconvenience  in  placing  his  feet  upon  small  surfaces. 
Thus,  when  he  attempts  to  enter  a  carriage,  he  finds  it  difficult  to  guide 
his  foot  to  the  step,  and  in  mounting  a  horse  he  cannot  readily  hit  the 
stirrup.  A  gentleman  from  Maryland,  who  is  now  a  patient  of  mine, 
and  who  is  affected  with  the  disease  in  question,  tells  me  that  among 
the  first  symptoms  which  he  noticed  was  the  difficulty  he  experienced 
in  putting  his  foot  into  the  stirrup.  He  was  obliged  to  use  his  hand  as 
a  guide.  A  like  trouble  is  frequently  experienced  in  ascending  a  stair- 
case. 

The  gait  of  a  person  suffering  from  locomotor  ataxia  is  very  much 
changed  from  that  which  is  natural.  Instead  of  the  foot  being  placed 
upon  the  ground  with  an  easy  motion,  "the  heel  a  little  in  advance  of 
the  sole,  and  the  latter  gliding  down  gently,  the  leg  is,  as  it  were,  jerked 
forward,  the  heel  comes  down  suddenly,  and  the  sole  follows,  at  a  con- 
siderable interval,  with  an  abrupt  flapping  motion.  In  ordinary  walking 
the  placing  of  the  foot  on  the  ground  consists  of  one  movement — there 
being  no  stoppage  between  the  touching  of  the  ground  by  the  heel  and 
the  planting  of  the  sole  of  the  foot;  but,  in  the  gait  of  a  person  affected 
with  posterior  spinal  sclerosis,  the  foot  is  placed  on  the  ground  by  two 
distinct  movements,  one  for  the  heel  and  another  for  the  sole  of  the 
foot. 

But,  besides  these  irregularities  of  the  progressive  movements,  there 
are  others  which  are  likewise  notable.  The  leg  is  not  carried  directly 
forward,  but  is  thrown  out  a  little  from  the  median  line,  and  this  gives 
the  patient  a  motion  like  that  of  one  walking  on  a  tight-rope,  and  bal- 
ancing himself  with  a  pole.  The  object  of  this  movement  is  doubtless 
to  widen  the  base,  and  thus  to  enable  the  patient  to  preserve  more 
readily  his  centre  of  gravity  within  it.  In  standing,  he,  for  the  same 
reason,  always  separates  the  feet  to  a  greater  than  normal  distance. 

In  walking  or  standing,  it  will  be  observed  that  the  patient  affected 
with  sclerosis  of  the  posterior  root-zones  of  the  spinal  cord  keeps  his 
eyes  fixed  on  his  feet,  or  on  the  ground  a  little  distance  in  advance. 
He  is  obliged  to  do  this  for  the  reasons — which  with  others  will  be 
more  fully  considered  under  the  head  of  pathology — that  the  sensibility 
of  the  soles  of  the  feet  being  diminished,  and  the  muscular  sensibility 
being  also  lessened,  he  is  deprived,  to  a  great  extent,  of  the  chief  means 
by  which  he  was  formerly  enabled  to  recognize  the  position  of  his  feet, 
and  of  the  dynamic  condition  of  his  muscles.  He  hence  is  obliged  to 
make  use  of  another  sense — his  vision — in  order  to  obtain  the  necessary 
information.  Therefore,  when  he  shuts  his  eyes,  or  is  obliged  to  walk 
in  the  dark,  he  is  deprived  of  the  assistance  of  his  eyesight,  and,  having 
only  his  diminished  tactile  and  muscular  sensibility  to  guide  him,  moves 
in  an  exceedingly  timid  and  disorderly  manner,  or  else  is  unable  to  walk 
at  all. 


PROGRESSIVE   LOCOMOTOR  ATAXIA.  571 

Under  some  circumstances  he  is  unable  to  go  forward,  even  with 
the  assistance  of  his  evesight.  Experience  has  taught  him  that  he  can- 
not rely  on  very  important  senses,  which  formerly  he  implicitly  trusted. 
He  loses  confidence  in  them,  and  is  not  reassured,  even  with  vision  to 
assist  him.  He  therefore  uses  extraordinary  caution  in  walking  over  a 
tiled  floor,  on  the  ice  or  snow,  in  descending  a  staircase,  or  in  crossing 
a  street  crowded  with  vehicles.  In  a  recent  clinical  lecture,'  delivered 
to  the  class  of  the  Bellevue  Hospital  Medical  College,  I  called  special 
attention  to  this  phenomenon  of  loss  of  confidence,  and  adduced  severa. 
cases  in  illustration  of  this  point. 

That  there  is  little  paralysis  of  motion  to  account  for  these  abnor- 
malities, can  be  readily  shown  by  a  few  inquiries  and  experiments. 
Thus  it  will  ordinarily  be  found  that  the  patient  who  is  unable  to  stand 
with  his  eyes  shut,  or  take  a  step  in  the  dark,  can  push  strongly  with 
his  legs,  or  walk  a  short  distance  with  a  good  deal  of  vigor.  He  is  still 
good  for  a  "  spurt,"  but  long-continued  muscular  effort  fatigues  him. 

When  the  lesion  is  above  the  origin  of  the  nerves  which  go  to  form 
the  brachial  plexus,  the  upper  extremities  are  the  seat  of  symptoms 
which  are  similar  to  those  described  as  manifesting  themselves  in  the 
legs.  There  are  numbness  and  other  indications  of  anaesthesia,  together 
with  more  or  less  difficulty  in  coordinating  the  muscles  into  harmonious 
action.  The  patient  finds  that  the  ends  of  his  fingers  have  lost,  to  some 
extent,  their  acute  tactile  sensibility,  and  that  there  is  restraint  in  the 
management  of  the  fingers.  He  experiences  these  difficulties  in  button- 
ing his  clothes,  in  picking  up  a  pin,  in  writing,  and  in  other  actions 
requiring  nice  manipulation.  If  he  attempts,  for  instance,  to  carry  a 
glass  of  wine  to  his  lips,  he  spills  a  portion  of  the  contents  ;  and,  if  told 
to  place  his  finger  on  any  particular  part  of  his  face,  the  movement  is 
accomplished  with  a  wabbling  motion,  and  the  finger  is  darted  suddenly 
to  the  part  as  it  approaches  it.  All  persons  possess  a  knowledge  of 
where  the  different  parts  of  their  bodies  are  situated,  which  does  not 
depend  upon  the  sense  of  sight,  although  probably  acquired  by  that 
sense  and  experience.  There  is  such  an  intimate  and  exact  relation  be- 
tween the  ends  of  the  fingers  and  the  cutaneous  surface  of  the  body 
that,  if  a  spot  no  bigger  than  the  head  of  a  pin  be  made  with  a  pencil 
on  the  forehead,  a  person  can  close  his  eyes  and  touch  it  with  the  end 
of  his  finger  without  difficulty  every  time  he  makes  the  attempt.  He 
can  also,  with  the  eyes  shut,  carry  the  end  of  his  fingers  straight  to  the 
tip  of  his  ear,  the  middle  of  his  eyebrow,  or  any  other  part  of  his  body 
within  reach.  A  person,  however,  laboring  under  sclerosis  of  the  pos- 
terior root-zones  of  the  spinal  cord,  cannot  do  any  of  these  things.  He 
loses,  at  a  very  early  period  of  the  disease,  thai  intimate  topographical 
relation  which  exists  between  the  ends  of  the  fingers  and  the  rest  of  the 

1  "  Clinical  Lectures  on  Diseases  of  the  Nervous  System,"  Journal  of  Psychological 
Medians,  January,  1871. 


572 


DISEASES  OF   THE  SPINAL   CORD. 


body  ;  and  hence,  when  he  closes  his  eyes,  and  attempts  to  put  the  tip 
of  his  index-finger  on  the  end  of  his  nose,  he  misses  his  aim,  sometimes 
by  as  much  as  two  or  more  inches. 

M.  Onimus  '  has  called  attention  to  the  fact  that  important  indica- 
tions are  afforded  by  an  examination  of  the  handwriting  of  ataxics,  the 
defective  power  of  coordination  being  well  shown  even  when  the  eyes 
are  open,  but  being  still  more  strongly  manifested  when  they  are  shut. 
The  difficulty  which  they  experience  is  in  making  the  round  letters, 
such  as  <7,  c,  and  o.  Besides  the  incoordination  there  is  a  jerking 
movement  of  the  pen,  and  a  kind  of  impidse  to  continue  writing  after  the 
word  is  finished.  Finally,  when  the  ataxia  of  the  arm  is  at  its  height, 
there  is  an  impossibility  of  writing  a  single  word,  and  we  obtain  only 
a  set  of  traces  confused  and  without  order.  I  am  able,  after  many  ex- 
periments, to  confirm 
FlG-  r3-  the  foregoing  obser- 

vations. In  Fig.  73, 
a,  is  seen  the  attempt 
of  a  patient  with  his 
eyes  open,  and  look- 
ing at  his  pen,  to  write 
the  word  "  Civiliza- 
tion." At  b  is  a  like 
attempt  made  when 
the  eyes  were  shut. 
As  in  the  legs,  when  the  lesion  is  so  low  down  in  the  cord  as  only 
to  affect  them,  there  is  no  well-marked  paralysis.  The  grip  of  the  pa- 
tient is  strong,  and  the  dynamometer  shows  the  existence  of  consider- 
able strength.  He  is,  however,  not  capable  of  continued  muscular 
effort ;  and,  though  he  may  be  able  to  lift  several  hundred  pounds,  or  to 
cany  another  person  around  the  room,  his  muscles  are  exhausted  with 
the  gradual  and  regular  expenditure  of  a  much  less  amount  of  force. 

A  phenomenon  is  often  noticed  as  regards  the  upper  extremities, 
which  also  exists  with  the  lower,  but  which  cannot  be  so  readily  mani- 
fested— and  that  is,  that  the  patient  loses  the  ability  to  distinguish 
even  considerable  differences  between  weights.  In  the  normal  condi- 
tion, if  two  weights,  differing  in  the  ratio  of  thirty-nine  to  forty,  are 
put  one  in  one  hand  and  one  in  the  other,  the  difference  is  perceived 
without  difficulty.  The  lower  extremities,  according  to  Jaccoud,  are 
not  so  sensitive,  and  cannot  distinguish  a  less  difference  than  from 
about  fifty  to  seventy  grammes. 

A  person  affected  with  locomotor  ataxia,  due  to  sclerosis  of  the 
posterior  root-zones  above  the  origins  of  the  nerves  which  form  the 
brachial   plexus,  may  have  an  ounce-weight  put  into  his  hand,  and 

1  Gazette  medicale,  February  21,  1874  ;  also,  Chicago  Journal  of  Nervous  and  Mental 
Diseases,  April,  1874,  p.  254. 


PROGRESSIVE   LOCOMOTOR   ATAXIA. 


5T3 


if  in  a  few  seconds  it  be  removed,  and  one  of  half  an  ounce  be  substi- 
tuted, he  will  not  be  able  to  tell  correctly  which  is  the  heavier.  Or 
both  hands  may  be  extended,  and  the  two  weights  placed  simul- 
taneously in  them.  The  eyes  should,  of  course,  be  closed.  Some- 
times less  differences  can  be  perceived,  but  ordinarily  greater  ones 
are  not  distinguished.  In  the  case  of  a  gentleman  now  under  my 
charge,  there  is  an  impossibility  of  telling  which  of  two  pieces  of 
lead,  the  one  weighing  one  ounce  and  the  other  a  pound,  is  the  heavier. 
Spath  '  states  that,  in  a  case  under  his  charge,  the  patient  could  not 
distinguish  between  two  weights,  which  differed  as  one  to  one  hundred. 
No  means  for  measuring  the  extent  to  which  the  patient  is  able  to 
determine  the  state  of  muscular  contraction  is  at  all  comparable  to  the 
dynamograph.  The  range  of  its  usefulness  is,  however,  limited — owing 
to  the  fact  that  posterior  spinal  sclerosis  is  not  very  frequently  seated 
high  enough  in  the  cord  to  affect  the  muscles  of  the  upper  extremities. 
When  the  lesion  is  not  above  the  origin  of  the  nerves  which  go  to  form 
the  brachial  plexus,  the  line  is  straight,  as  in  the  accompanying  figure, 

Fig.  74. 


which  represents  the  tracing  made  by  a  patient  suffering  from  sclerosis 
of  the  posterior  root -zones  in  the  lower  dorsal  region  of  the  cord.  But, 
when  the  seat  of  the  disease  in  the  cord  is  an}-where  between  the  fifth 
cervical  and  first  dorsal  vertebrae,  the  ability  to  maintain  a  uniform 
degree  of  pressure  is  impaired,  and  lines  resembling  the  following  are 
produced  : 


Fio.  75. 


Both  the  above  were  made  by  the  same  patient,  the  upper  with 
the  right  and  the  lower  with  the  left  hand.  He  was  perfectly  confi- 
dent, till  I  showed  him  the  tracings,  that  he  had  exerted  a  uniform 
pressure  while  the  paper  was  traversing  the  pencil. 

1  "Beitr&ge  but  Lehre  von  der  Tabes  dorealis,"  Tubingen,  1864. 


574  DISEASES   OF   THE   SPINAL   CORD. 

Under  the  name  of  barsesthesiometer,  Eulenberg1  has  described  an 
instrument  for  estimating  the  sense  of  pressure,  by  means  of  which  very- 
accurate  determinations  can  be  made  for  different  parts  of  the  body. 
He  succeeded  in  demonstrating  a  considerable  impairment  of  the  sense 
of  weight  in  the  great  majority  of  cases  of  locomotor  ataxia  exam- 
ined, even  when  sensibility  to  pain,  tickling,  or  electric  irritation,  was 
but  slightly  affected,  and  the  sense  of  temperature  was  normal. 

The  reflex  excitability  of  the  skin  is  generally  notably  increased. 
The  touch  of  the  bedclothes,  or  even  the  rubbing  of  one  leg  against 
the  other,  is  sufficient  to  cause  strong  contractions.  Involuntary 
movements  of  the  limbs,  independent  of  those  due  to  reflex  excita- 
tions, are  rarely  met  with. 

A  symptom  first  pointed  out  by  Westphal2  is  the  absence  or  nota- 
ble diminution  of  the  reflex  excitabilitj7  of  the  tendons.  It  is  generally 
best  exhibited  by  causing  the  patient  to  cross  one  leg  over  the  other 
and  then  to  strike  with  the  side  of  the  hand  the  tendon  of  the  quadri- 
ceps extensor  just  below  or  just  above  the  patella.  It  will  be  found 
that  there  is  very  slight  and  often  no  movement  whatever  of  the  leg. 
In  the  healthy  subject,  involuntary  extension  of  the  leg  at  once  takes 
place.  This  symptom,  though  occasionally  absent,  as  I  have  found,  is 
yet  so  generally  present,  even  in  the  early  stage  of  locomotor  ataxia, 
as  to  make  it  a  sign  of  considerable  diagnostic  importance. 

The  electro-muscular  contractility  is  generally  increased.  In  some 
few  instances  I  have  found  it  normal,  and  in  still  fewer  diminished. 
There  are  no  polar  degenerative  reactions. 

It  has  already  been  mentioned  that  there  are  frequently  ocular 
troubles.  These  generally  occur  among  the  early  symptoms,  and  relate 
either  to  vision,  to  the  movements  of  the  eyeball,  or  to  both.  Indeed, 
the  very  first  symptoms  may  be  connected  with  the  eye  or  the  nerves 
supplying  its  muscles.  Thus  there  may  be  amaurosis  due  to  gray 
atrophy  of  the  optic  nerve,  or  of  the  disk,  a  condition  readily  detected 
by  the  ophthalmoscope  ;  or  the  third  pair  of  nerves  may  be  involved, 
causing  ptosis,  divergent  strabismus,  and  dilatation  of  the  pupil ;  or 
the  sixth  pair  of  nerves  alone  may  be  affected,  causing  convergent 
strabismus  ;  or  there  may  be  only  contraction  of  the  pupil  and  promi- 
nence of  the  eyeball  from  the  irritation  propagated  from  the  cilio- 
spinal  centre  through  the  sympathetic  nerves.  In  the  majority  of 
cases  the  iris  loses  its  reflex  action  to  light,  but,  as  Argyll-Robertson 
first  pointed  out,  still  retains  the  power  of  contraction  and  dilatation 
for  accommodation.  These  ocular  troubles  never  take  place  in  sclero- 
sis of  the  posterior  root-zones  existing  below  the  cilio-spinal  centre — 
the  upper  dorsal  region  of  the  cord. 

1  Ally.  Med.  I "<  nt.-Zcilung,  No.  93,  1869;  also,  Journal  of  Psychological  Medicine, 
October,  1*70,  p.  622. 

2  "Archiv  fur  Psychiatric,  unci  Ncrvcnkrankhciten,"  B.  v.,  s.  819. 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  375 

Galezowski '  has  called  attention  to  a  very  important  fact  in  con- 
nection with  the  ocular  disturbances  of  ataxics,  and  that  is,  the  loss  of 
the  ability  to  distinguish  certain  tints  and  colors.  Thus  patients  affect- 
ed with  locomotor  ataxia,  and  who  are  at  the  same  time  amaurotic 
from  gray  atrophy  of  the  optic  nerves,  are  unable  to  distinguish  the 
secondary  tints  of  the  scale  (1  to  5,  Plate  F),  and  lose  the  perception  of 
red  and  of  green.  The  perception  of  yellow  and  blue  is  not  lessened  ; 
on  the  contrary,  it  appears  in  some  cases  to  be  rendered  abnormally 
delicate.  I  have  frequently  verified  the  extrera^  value  of  these  tests,  and 
have  often  observed  the  phenomena  referred  to  when  there  was  no  other 
disturbance  of  normal  vision,  so  far  as  all  type-tests  were  concerned. 

Another  organ  liable  to  functional  derangement  and  even  organic 
disease  as  effects  of  locomotor  ataxia  is  the  heart.  Attention  was  first 
directed  to  this  point  by  Berger  and  Rosenbach,2  who,  in  a  monograph 
based  on  seven  cases,  arrived  at  the  conclusion  that  aortic  insufficiency 
was  the  condition  induced.  But  in  a  recent  paper  on  the  subject  of 
the  relation  between  locomotor  ataxia  and  cardiac  lesions,  M.  Gras- 
set 3  shows,  from  two  cases  occurring  in  his  own  experience,  and  the 
citation  of  fifteen  others  from  different  writers,  that  the  influence  is 
not  such  a  restricted  one  as  supposed  by  Berger  and  Rosenbach,  and 
that  the  influence  is  such  as  would  be  produced  by  acute  suffering  of 
any  kind.  He  shows  very  conclusively  that  there  is  no  direct  relation 
between  the  spinal  affection  and  the  heart,  but  that  the  agonizing 
pains  which  the  patient  affected  with  locomotor  ataxia  usually  Buffers, 
are  the  cause  of  the  heart-troubles.  To  use  his  own  language  :  "  Ex- 
periments prove  the  undoubted  influence  of  peripheral  excitations  and 
painful  sensations  on  the  heart.  They  show  that  it  is  possible  that,  with 
man,  pains,  if  long  continued,  affect  the  heart  in  an  abnormal  way  and 
induce  disease  of  the  organ.  Physiology  simply  indicates  the  possi- 
bility  ;  clinical  experience  establishes  the  reality.'''' 

The  disturbances  in  the  healthy  action  of  the  stomach  and  intes- 
tines which  have  already  been  alluded  to  as  common  initial  symptoms, 
an-  sometimes  very  distressing.  As  the  pains  in  the  limbs  are  often 
taken  for  evidences  of  neuralgia  or  rheumatism,  so  these  gastric  ami 
intestinal  troubles  are  frequently  regarded  as  indicating  the  existence 
of  dyspepsia.  I  have  had  a  number  of  patients  under  my  charge  who, 
with  double  vision,  ptosis,  contracted  or  unequal  pupils,  incoordination, 
and  tin'   other  symptoms   of  locomotor  ataxia,  had    been   told   that  "it 

was  all  dyspepsia,"  because  vomiting  and  gastric  pain  were  prominent 

1  "  I)u  di  i  -  maladies  d<-s  yi-ux  par  la  eliiomatOBCOpie  retinienne,"  etc.,  Paris, 

18fi8;  also, "  Echellcs  typographiquee  el  chromatiquee  pour  L'examen  de  I'acuite*  nsuelle,'' 
Vans,  1874. 

a  "  Oebcr  die  Coinddenz  von  Tali  -  Doi  lalia  und  [naufficienz  der  Aorten-Klappen,*1  fi  r- 
itn.r  klin.  Woclietuchrijt,  No.  '-'7,  1879,  p.  I"~'. 

'•  Ataxic  locotnotrioe  ct  lea  !6sioni  cardiaques,"  ifontpeUier  Midical,  Juin,  18S0. 


576  DISEASES  OF  THE   SHXAL  CORD. 

features  of  the  disease.  These  symptoms  are  also  due  to  the  relations 
of  the  sympathetic  nerves  with  the  spinal  cord,  and  are  not  present  in 
cases  where  the  lesion  is  low  down  in  the  lumbar  region. 

When,  however,  this  part  of  the  cord  is  involved,  there  are  very 
remarkable  disorders  of  the  genital  system.  These  consist  of  frequent 
nocturnal  emissions  with  or  without  erections,  or  of  an  inordinate  desire 
for  sexual  intercourse.  A  gentleman  who  consulted  me  a  few  weeks 
ago,  and  who  was  affected  with  the  disease  in  question,  informed  me 
that  he  had  several  times  had  as  many  as  eight  seminal  emissions  in 
one  night,  and  that  his  sexual  desire  was  almost  inextinguishable. 

Paralysis  of  the  bladder  is  a  common  circumstance,  and  the  sphinc- 
ter is  not  infrequently  likewise  affected.  The  bowels  are  usually  obsti- 
nately constipated. 

The  feeling  of  constriction  around  the  body,  which  is  so  common  a 
symptom  in  acute  myelitis,  and  which  is  met  with  in  other  organic 
affections  of  the  cord,  is  rarely  absent  in  cases  of  sclerosis  of  the  pos- 
terior columns. 

Although  the  course  of  the  disease  in  the  great  majority  of  cases  is 
onward  to  a  fatal  termination,  there  are  often  periods  of  remission,  as 
in  other  spinal  affections,  and  it  rarely  happens  that  the  duration  is  not 
several  years.  A  gentleman  from  Westchester  County,  in  this  State, 
has  been  affected  for  over  twenty  years,  and  still  walks  tolerably  well. 
Another  from  Boston  had  been  subject  to  the  disease  for  over  twelve 
years.  When  I  first  saw  him  he  could  not  stand  with  his  eyes  shut, 
had  the  characteristic  ataxic  gait,  was  subject  to  genital  and  urinary 
troubles,  but  yet  was  no  worse  than  he  had  been  six  years  previously. 
He  visited  me  again  in  October,  1875,  walking  as  well  as  when  I  saw  him 
originally,  but  still  subject  to  the  electric-like  pains  in  as  great  degree 
as  ever.  Another,  from  Pittsburg,  has  been  in  a  stationary  condition 
for  several  years  ;  and  another,  from  Binghamton,  in  this  State,  remains 
about  as  he  was  three  years  ago.  I  could  easily  cite  twenty  others 
whom  I  occasionally  see  professionally,  who  hold  their  own,  and  who 
have  been  affected  for  from  five  to  ten  years.  Romberg  gives  the 
average  duration  at  from  ten  to  fifteen,  Jaccoud  at  from  six  to  eight, 
and  all  authors  agree  that  the  course  is  slow.  Of  the  many  patients 
affected  with  sclerosis  of  the  posterior  columns  of  the  spinal  cord  who 
have  been  under  my  charge  during  the  last  ten  years,  five  only  have 
as  yet  died,  so  far  as  I  am  aware.  Of  these,  one  had  been  affected 
seven  years,  one  eight  years,  two  about  ten  years,  and  one  eight  and  a 
half  years.  There  are  several  eases  now  under  my  charge  in  which  the 
affection  has  existed  longer  than  either  of  these  terms. 

The  advance  of  the  disease  in  the  cord  causes  an  aggravation  of  alL 
the  symptoms,  and  the  appearance  of  others  not  previously  noticed. 
The  loss  of  motor  power  is  now  a  prominent  feature,  the  muscles  be- 
come atrophied,  bed-sores  make  their  appearance,  there  is  anasarca,  and 


PROGRESSIVE    LOCOMOTOR   ATAXIA.  577 

the  patient,  if  not  carried  off  by  some  intercurrent  affection,  dies  of  the 
extreme  exhaustion  induced  by  his  disease. 

Among  the  anomalies  of  sclerosis  of  the  posterior  root-zones  of  the 
spinal  cord,  the  joint  affections  are  especially  worthy  of  attention. 
Their  connection  with  posterior  spinal  sclerosis  was  first  indicated  by 
Charcot.1  Previous  to  his  observations,  they  had  been  noticed,  but  they 
were  ascribed  to  an  intercurrent  rheumatism,  and,  many  years  before 
locomotor  ataxia  was  recognized  as  an  independent  disease,  the  asso- 
ciation of  spinal  disease  with  inflammation  of  the  joints  was  pointed 
out  by  Prof.  J.  K.  Mitchell,8  of  Philadelphia  ;  and  his  son,  Dr.  S.  Weir 
Mitchell,  with  Drs.  Morehouse  and  Keen,3  had  also  related  cases  in 
which  wounds  of  the  spine  had  been  followed  by  arthritis.  Since 
Charcot's  paper  was  published,  Dr.  Benjamin  Ball4  has  cited  cases  of 
like  affections  coexisting  with  locomotor  ataxia.  In  the  cases  in  ques- 
tion there  is  no  fever,  redness,  or  pain.  Generally  these  accidents  dis- 
appear without  leaving  permanent  organic  changes  behind  them,  but 
in  some  cases  the  head  of  the  bone  may  be  absorbed,  and  spontaneous 
dislocation  be  the  result. 

Of  the  cases  of  locomotor  ataxia  which  have  come  under  my  obser- 
vation, in  nine  only  were  there  any  troubles  of  the  joints. 

Death  may  take  place  either  as  the  direct  consequence  of  the  lesion 
of  the  spine,  or  as  the  result  of  some  intercurrent  affection,  such  as 
pneumonia,  dysentery,  phthisis,  or  cystitis,  or  by  disturbances  of  respi- 
ration and  circulation,  or  paralysis  of  the  muscles  of  deglutition  by 
the  extension  of  the  disease  upward,  so  as  to  reach  the  phrenic  nerves, 
or  medulla  oblongata. 

A  psychical  form  of  locomotor  ataxia  mentioned  by  some  authors 
oan  scarcely  be  said  to  exist.  It  is  true  that  some  patients  are  pecul- 
iarly subject  to  mental  depression,  and  to  attacks  of  temporary  excite- 
ment,  with  wakefulness  ;  but  the  rule,  according  to  my  experience,  is 
that  by  far  the  greater  number  preserve  a  very  calm  and  equable 
frame  of  mind,  and  such  is  the  conclusion  of  Steinhal b  and  Erb/ 

But  mental  disorder  of  a  very  decided  character  is  occasionally, 
though  rarely,  developed  toward  the  latter  stages  of  locomotor  ataxia. 
I  have  not,  however,  been  able  to  ascertain  that  this  is  particularly 
liable  to  assume  any  special  form.      It    may  be   intense  melancholia,  or 

1  "Sur  quelqncs  arthropathies  qid  paraissenl  dependre  d'une  lesion  du  oervcan  on 
de  lamoSlle  epiniere,"  Archives  <l<  phvaioloaie,  No.  I,  January,  L868,  p.  181. 

•  American  Journal  of  Ike  Medical  8eiencee,  vol.  viii.,  1881,  p.  56. 

I  in  hot-Wounds  and  other  Injuries  of  Nerves,"  Philadelphia,  18(Vt. 
1  "On  Diseases  <>f  the  Joints  connected  with  Locomotor  Ataxy,"  .'A  licai  Titrn 
Gazette,  October  81,  1868. 

•  "Beitrage  zur Qeschichte  and  Pathologie  der  Tain--;  Dorsalis,"  Hufcland'8  Journal, 
Han.]  98,  1844. 

•  "Oi.mr  Degeneration  der  1 1  int  .-r- 1  f.iii-_r.-,"'  Ziemeeen'a  Hondbuth,  elf  ter  Band,  aweite 
Nil  ftp,  p.  184. 

38 


578  DISEASES  OF  THE  SPINAL  CORD. 

general  mania,  or  general  paralysis  of  the  insane.  It  is  necessary  to 
bear  in  mind,  especially  as  regards  the  last-named  complication,  that 
it  is  altogether  different  from  a  brain-disease  with  ataxic  phenomena. 
There  is  a  form  of  general  paralysis  of  the  insane  in  which  there  are 
difficulties  of  coordination  and  other  tabetic  symptoms,  but  here  the 
cerebral  manifestations  are  first  in  order  ;  whereas,  in  locomotor  ataxia, 
the  spinal  disorder  is  the  primary  trouble,  and  the  cerebral  altogether 
secondary.  Westphal '  was  the  first  to  direct  attention  to  the  ataxic 
form  of  general  paralysis  of  the  insane,  and  to  show  that  the  disorders 
of  movement  which  are  exhibited  are  due  to  degeneration  of  the  pos- 
terior columns  of  the  spinal  cord. 

Several  instances  of  mental  disorder  supervening  toward  the  ter- 
mination of  locomotor  ataxia  have  come  under  my  observation,  and  in 
one  of  them  the  development  was  so  rapid  as  to  preclude  the  idea  that 
it  was  due  to  any  extension  of  the  disease  directly  to  the  brain.  The 
form  of  mental  derangement  in  this  case  was  acute  mania,  and  the 
patient  died,  after  a  paroxysm  of  intense  excitement,  in  a  condition  of 
profound  coma. 

In  another  case  there  were  repeated  epileptiform  convulsions,  with 
stupor  during  the  intervals,  and  in  which  latter  condition  death  ensued. 

Friedreich 2  has  called  attention  to  an  affection  of  the  spinal  cord 
occurring  very  rarely  in  children,  which  he  regards  as  a  hereditary  or 
family  form  of  locomotor  ataxia,  but  which,  from  an  experience  of  four 
cases,  and  detailed  descriptions  of  six  others  occurring  in  the  practices 
of  Drs.  W.  C.  Warren,  of  Holly  Springs,  Mississippi,  and  E.  S.  Coleman, 
of  Hollywood,  Arkansas,  I  am  disposed  to  think  is  not  locomotor  ataxia, 
but  a  hitherto  unrecognized  spinal  disease.  It  begins  in  early  life,  and  is, 
at  least  in  the  early  stages,  not  so  much  characterized  by  incoordination 
as  by  muscular  weakness.  In  the  cases  I  have  witnessed,  the  children, 
brothers  in  two  instances,  presented  the  appearance  of  old  men,  but 
were  able  to  walk  as  well  with  the  eyes  shut  as  with  them  open,  and 
to  stand  with  closed  eyes  without  any  unusual  swaying  of  the  body. 
In  none  of  the  cases  was  there  any  hereditary  tendency,  but,  as  I  have 
said,  my  cases  are  two  pairs  of  brothers.  Dr.  Warren's  cases,  three  in 
number,  were  children  of  the  same  parents  ;  as  were  also  Dr.  Coleman's 
three  cases.  All  my  cases  are  males  ;  of  Dr.  Warren's  cases  two  were 
boys  and  one  a  girl  ;  of  Dr.  Coleman's  cases  all  were  boys.  Friedreich 
is  of  the  opinion  that  this  form  is  more  common  in  girls  than  in  boys. 
I  think  it  somewhat  doubtful  whether  the  cases  he  cites  are  of  the 
same  character  as  those  which  have  come  to  my  knowledge,  and  I  re- 
frain from  any  further  discussion  of  the  subject  till  I  have  more  thor- 

1  "Tabes  Dorsualis  und  Paralysie  universal  progressive,"  Zcilschrift  fur  Psychiatric, 
Band  xx.,  1863;  und  xxi.,  1S64. 

2  "TJeber  ataxia  mit  bcsonderer  Beriieksichtigung  der  hereditarcn  Formcn,"  VirchoiSs 
Archiv,  Band  68,  1S76  ;  Band  70,  1877. 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  579 

oughly  studied  the  symptoms  and  pathogeny,  through  the  instances 
within  the  range  of  my  own  observation. 

Causes. — I  have  been  very  unsuccessful  in  my  efforts  to  ascertain 
the  cause  in  the  greater  number  of  persons  affected  with  progressive 
locomotor  ataxia  who  have  been  under  my  observation.  The  opinion 
is  very  prevalent  that  it  is  generally  the  result  of  excessive  venereal  in- 
dulgence ;  and,  although  this  is  undoubtedly  sometimes  a  cause,  it  cer- 
tainly is  not  so  common  a  one  as  is  generally  supposed.  I  have  care- 
fully inquired  into  the  etiology  of  all  the  cases  I  have  seen,  and  have 
only  been  able  to  assign  inordinate  sexual  indulgence  as  the  cause  in  a 
very  small  proportion.  The  impression  has  probably  arisen  from  the 
fact  that  there  are  frequently  aberrations  of  the  sexual  function  as  phe- 
nomena of  the  disease.  Injuries  and  exposure  to  cold  and  dampness 
were  apparently  the  causes  in  some  cases,  standing  in  a  constrained  po- 
sition— three  cases  in  railway  conductors — in  others,  the  excessive  use  of 
alcoholic  liquors  in  a  larger  proportion,  and  syphilis  in  probably  one- 
twentieth  of  the  cases.  In  the  majority,  however,  no  cause  can  reason- 
ably be  assigned.  As  regards  the  predisposing  causes,  it  is  certainly 
more  common  in  men  than  in  women — four  cases  only  in  my  experience 
pertaining  to  the  female  sex.  The  age  from  twenty-five  to  forty  is  that 
in  which  it  most  frequently  appears.  There  seems  to  be  no  direct 
hereditary  influence  to  the  disease. 

Diagnosis. — A  consideration  of  the  symptoms  detailed  in  the  fore- 
going pages  will  prevent  posterior  spinal  sclerosis  from  being  confound- 
ed with  any  other  affection  of  the  spinal  cord.  It  may,  however,  be 
difficult  at  times  to  discriminate  between  it  and  the  lesions  of  the  cere- 
bellum, and  the  distinction  has  frequently  not  been  made  by  very  skill- 
ful diagnosticians.  At  one  time  Duchenne  held  the  view  that  locomo- 
tor ataxia  was  really  the  result  of  a  lesion  of  the  cerebellum,  but  he 
subsequently  '  retracted  this  opinion,  and  accepted  the  doctrine  that 
the  spinal  cord  is  the  seat  of  the  disorder. 

In  a  recent  memoir2  I  have  endeavored  to  point  out  the  differences 
between  cerebellar  disease  and  the  affection  now  called  posterior  spinal 
sclerosis.  In  that  essay  I  have  said:  "Derangement  of  locomotion 
certainly  does  result  from  injury  or  disease  of  the  cerebellum.  Experi- 
mental physiology,  as  well  as  pathology,  proves  this.  Beyond  a  doubt 
the  disorder  is,  however,  clearly  due  to  vertigo.  There  are,  moreover, 
headache,  vomiting,  and  eventually  in  some  cases  hemiplegia,  generally 
of  the  opposite  side  to  that  of  the  cerebellar  lesion,  a  fact  at  variance 
with  Larrey's  assertion.     The  gait  of  a  person  thus  affected  is  exactly 

'  "  Diagnostic  differential  des  affections  c6r6belleuscs  ct  dc  l'ataxie  loeomotrice  pro- 
gressive," Gazette  hebdomadaire,  1866. 

•  "The  Physiology  and  Pathology  of  the  Cerebellum,"  Journal  of  Psychological  lA</» 
cfo,  April,  1869. 


580  DISEASES  OF  THE   SPINAL   CORD. 

similar  to  that  of  a  drunken  man.  As  Carre  says,  the  movements  are 
not  abrupt,  jerking,  and  exaggerated,  as  they  are  in  locomotor  ataxia. 
They  are  more  uncertain,  and  do  not  depend  upon  any  defect  of  co- 
ordination, but  upon  weakness  of  the  voluntary  power. 

"When  either  of  the  peduncles  of  the  cerebellum  is  affected  there 
is  an  irresistible  impulse  to  go  sideways,  and  sometimes  gyratory  move- 
ments are  produced." 

The  characteristic  symptom  of  cerebellar  lesion  is  vertigo  ;  and, 
although  this  is  sometimes  met  with  in  sclerosis  of  the  posterior  root- 
zones,  it  is  not  a  prominent  feature,  and  is  rarely  present  at  all  except  in 
the  very  earliest  stage. 

In  the  cerebellar  lesions  the  cutaneous  sensibility  is  unimpaired, 
whereas  in  posterior  spinal  sclerosis  it  is  always  diminished. 

A  patient  with  disease  of  the  cerebellum  can  stand  and  walk  better 
with  his  eyes  shut  than  with  them  open,  for  the  vertigo  is  not  in  the 
former  condition  felt  to  the  same  extent.  The  reverse  is  true  of  loco- 
motor ataxia.  The  history  of  the  case  will  also  serve  as  a  good  guide 
to  the  diagnosis.  In  the  latter  or  even  in  the  developed  stage  of  loco- 
motor ataxia  it  would  be  difficult  to  mistake  it  for  any  other  affec- 
tion. 

Prognosis. — The  prognosis  is  no  more  favorable  than  that  of  ante- 
rior or  lateral  spinal  sclerosis.  A  few  cases  are  cured,  more  are  relieved, 
but  the  great  majority  go  on  unchecked.  Of  the  cases  which  have  come 
under  my  observation,  seven  were  cured,  and  they  were  subjected  to 
treatment  from  a  very  early  stage.  Of  these,  four  were  probably  of 
syphilitic  origin,  but  in  the  other  three  no  such  cause  was  at  all  probable. 
One  of  them  was  a  woman. 

The  cases  in  which  amelioration  has  been  produced  are  more  numer- 
ous. In  fact,  it  is  not  at  all  uncommon  to  succeed  in  retarding  the  on- 
ward progress  of  the  disease,  and  of  thus  prolonging  the  life  of  the 
patient. 

Morbid  Anatomy. — Within  the  last  few  years  many  very  important 
contributions  have  been  made  to  the  morbid  anatomy  of  locomotor 
ataxia  mainly  by  the  pathologists  of  that  great  French  school  of  the 
Salpetriere  with  Charcot  at  its  head.  For  the  complete  understanding 
of  tbese  a  few  words  relative  to  the  normal  anatomy  of  the  parts  con- 
cerned are  necessary. 

In  embryonic  and  early  infantile  life  the  posterior  columns  are  di- 
vided into  two  unequal  parts  by  a  fissure  extending  from  the  angle  formed 
by  the  posterior  median  fissure  and  the  posterior  commissure  of  gray 
matter.  The  internal  or  median  part  is  wedge-shaped,  is  of  greater  extent 
in  the  cervical  region  than  in  the  dorsal,  and  greater  in  this  than  in  the 
lumbar.  It  is  called  the  posterior  median  column,  or  the  column 
of  Goll. 

The   external    part    of    the   posterior   column    is   all   that   region 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  581 

bounded  externally  by  the  posterior  horn  of  gray  substance  and  in- 
teriorly by  the  posterior  median  columns.  It  is  called  the  poste- 
rior external  column,  or  the  posterior  root-zone,  or  the  column  of 
Burdach. 

In  adult  life  the  fissure  separating  these  two  regions  no  longer  ex- 
ists, but  its  situation  is  generally  marked  by  a  furrow  on  the  periphery 
of  the  cord,  and  a  histological  difference  exists  between  them,  in  that 
the  posterior  median  columns  contain  a  greater  amount  of  connective 
tissue  than  do  the  posterior  external  columns,  and  the  nerve-fibres  in 
them  are  long  and  continuous,  while  those  in  the  latter  contain  many 
short  fibres,  which,  after  passing  upward  or  downward  for  a  short  dis- 
tance, leave  it ;  the  majority  of  them  entering  the  posterior  horn  of 
gray  substance,  the  minority  terminating  in  the  posterior  median 
column. 

Now,  although  it  often  happens  that  both  these  subdivisions  of  the 
posterior  columns  are  the  seat  of  the  alteration  giving  rise  to  loco- 
motor ataxia,  it  has  been  very  positively  shown  that  the  essential 
lesion  is  that  of  the  posterior  external  column,  and  that  it  is  to  the 
disease  of  these  regions  that  the  majority  of  the  peculiar  symptoms  of 
locomotor  ataxia  are  due. 

The  posterior  internal  columns  transmit  the  muscular  sense  for  the 
lower  limbs  and  trunk  only.  The  muscular  sense  tract  for  the  upper 
extremities  probably  lies  in  the  median  portion  of  the  posterior  exter- 
nal columns.  It  is  therefore  possible,  if  the  ataxia  is  limited  to  the 
upper  extremities,  to  find  the  lesion  confined  to  the  posterior  external 
columns. 

This  point  has  been  determined  by  a  case  very  thoroughly  investi- 
gated by  Pierret,1  in  which  a  woman  named  Moli  suffered  from  the 
electric-like  pains,  and  incoordination  of  locomotor  ataxia,  which  were 
mainly  experienced  in  the  upper  extremities.  On  post-mortem  exam- 
ination that  part  of  the  cord — the  cervico-dorsal — in  relation  with  the 
upper  extremities  was  found  to  be  sclerosed  in  a  thin  lamina  existing 
only  in  the  posterior  external  columns.  The  posterior  median  columns 
were  perfectly  healthy. 

In  another  case  the  same  observer  had  the  opportunity  of  confirm- 
ing the  view  that  the  posterior  median  columns  do  not  transmit  sen 
sory  impressions  from  the  upper  extremities.     A  woman  (Cutta)  had 
suffered  for  many  years  with  electric-like  pains  in  the  lower  extremi- 
ties, plantar  anesthesia,  and  incoordination.     Standing  and  walking 

were  impossible.  In  late  years  she  had  experienced  constricting  pains 
around  the  body.  The  superior  extremities  were  not  in  t lit*  least  in- 
volved. On  post-mortem  examination  the  posterior  columns  in  the 
lumbar  region  were  sclerosed   throughout    their  whole  extent,  except 

1  "Sur  lea  alterations  de  la  substance  pi-i  de  la  mofille  eplniere  dana  1'aUude  loco- 
motriec,"  etc.,  Archive*  de  physiologic  1870,  p.  .v.17. 


582  DISEASES   OF   THE   SPINAL   CORD. 

that  on  each  side  a  little  islet  of  healthy  tissue  remained.  At  the 
sixth  dorsal  vertebra  the  sclerosed  tissue  was  less  extensive  and  almost 
entirely  confined  to  the  posterior  median  columns,  the  posterior  ex- 
ternal columns  only  exhibiting  on  each  side  a  little  islet  of  sclerosed 
tissue.  A  little  higher  these  islets  disappeared,  and  the  lesion  was 
entirely  limited  to  the  posterior  median  columns.1 

Now,  if  the  posterior  median  column  is  not  exclusively  occupied 
by  fibres  transmitting  sensory  impressions  from  a  lower  level,  we 
should  not  be  able  to  account  for  the  entire  exemption  of  the  superior 
extremities  from  all  ataxic  phenomena,  for  the  posterior  median  col- 
umns in  that  part  of  the  cord  in  relation  with  them  were  the  seat  of 
marked  lesion. 

When  the  posterior  median  columns  are  the  seat  of  marked  dis- 
ease, it  is  more  than  probable  that  the  lesion  originates  in  the  poste- 
rior external  columns,  and  therefore  affects  the  former  secondarily. 
Pierret  expresses  the  opinion,  in  which  Charcot  concurs,  that  the  im- 
plication of  the  posterior  median  columns  is  a  phenomenon  analogous 
to  that  which  produces  an  ascending  median  sclerosis  as  a  result  of 
partial  myelitis,  and  that  the  lesion  is  only  produced  in  those  cases  in 
which  the  morbid  process  is  very  strongly  pronounced  in  the  lumbo- 
dorsal  region  of  the  cord. 

As  has  been  shown,  the  initial  lesion  of  tabes  begins  in  the  poste- 
rior external  columns.  Now,  it  is  through  these  columns  that  a  large 
proportion  of  the  sensory  fibres  pass  immediately  after  their  entrance 
into  the  spinal  cord,  and  it  is  the  slow  inflammation  and  destruction 
of  these  fibres  that  give  rise  to  the  group  of  symptoms  previously 
described.  Sensory  tracts  in  the  cord  degenerate  upward,  and  usually 
degenerate  slowly ;  hence,  as  the  disease  generally  begins  in  the  lower 
segments  of  the  cord,  a  considerable  interval  of  time  elapses  before 
symptoms  of  the  disease  appear  in  the  arms,  and  a  still  longer  time 
before  cerebral  symptoms  are  observed. 

It  is  not  always  the  case  that  the  morbid  process  stops  with  the 
posterior  columns  ;  the  posterior  horns  of  gray  matter,  the  lateral 
columns,  and  even  the  anterior  horns,  may  be  reached. 

As  to  the  spinal  nerves,  it  will  almost  invariably  be  found  that  the 
posterior  roots  are  atrophied  and  the  sensory  ganglia  diseased. 

The  intra-cranial  lesions  are  important.  Indeed,  there  is  reason 
to  think  that  they  are  often  the  starting-point  of  the  disease.  They 
have  been  very  carefully  studied  by  many  observers,  and  the  fact 
that  one  of  the  most  striking  of  them — that  of  the  optic  nerve — can 
be  observed  with  the  ophthalmoscope,  gives  additional  interest  to  the 
subject. 

The  alteration  which  the  optic  nerves  undergo  is  a  slow  progressive 

1  "  Note  sur  la  sclerose  des  cordons  postericurs  dans  l'ataxic  locomotrice  progres- 
sive," Archives  dc  pliysiologic,  tome  iv.,  18*71— "72,  p.  364. 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  583 

sclerosis,  causing  atrophy  of  the  disks  and  of  the  nerves  themselves. 
From  the  color  which  the  nerves  assume,  the  condition  is  known  by 
ophthalmologists  as  gray  degeneration.  According  to  Leber,  and  Weck- 
er  and  Jaeger,  the  essential  changes  met  with  in  gray  degeneration  of 
the  optic  nerve  are  a  marked  increase  in  the  quantity  of  connective 
tissue,  especially  of  the  cell-elements,  and  the  appearance  of  numerous 
grumous  cells.  The  lesion  is  therefore  of  the  same  character  as  sclero- 
sis affecting  the  other  parts  of  the  nervous  system. 

The  ophthalmoscopic  appearances  have  been  so  clearly  stated  by 
Wecker  and  Jaeger,1  that  1  quote  from  them  the  following  details  : 

"  The  clinical  characters  are  especially  revealed  by  the  particular 
appearance  of  the  papilla  and  by  the  narrowing  of  the  visual  field. 

"An  essential  sign  which  we  have  claimed  for  the  ophthalmoscopic 
image  of  gray  degeneration,  is  the  more  or  less  complete  absence  of  an 
atrophic  excavation.  It  is  of  course  easy  to  understand  that  such  ex- 
cavation is  much  less  apt  to  be  formed  when  there  is  a  substitution  of 
cellular  tissue  than  when,  as  in  simple  atrophy,  the  entire  nervous  struct- 
ure disappears. 

"  In  gray  degeneration  of  the  nerve  the  initial  signs  of  the  disease 
consist  in  a  simple  change  in  the  color  of  the  papilla  without  any  exca- 
vation. It  becomes  pale,  as  is  perceived  by  the  examination  of  the 
erect  image  with  Helmholtz's  plates,  and  it  assumes  a  more  or  less  pro- 
nounced bluish  tint. 

"With  this  change  of  color  there  is  a  coincident  change  in  the 
transparency  of  the  tissue  of  the  disk.  It  becomes  impossible  to  fol- 
low the  central  vessels  in  their  ramifications  ;  they  seem  to  be  applied 
to  the  bluish-white  tissue  of  the  papilla,  and  the  whitish  sclerotic  ring 
offers  a  marked  contrast  to  the  opaque  tissue  of  the  nerve." 

According  to  these  authors,  the  ophthalmoscopic  appearances  in 
cases  of  gray  degeneration  are  sufficiently  characteristic  to  enable  the 
diagnosis  of  locomotor  ataxia  to  be  made  with  certainty  from  them 
alone.  This  is,  however,  I  am  inclined  to  think,  too  positive  a  state- 
ment. We  may,  however,  safely  conclude  that  when  they  are  coexist- 
ent with  the  disturbance  of  chromatic  perception  previously  referred 
to  ;  when  the  pupils  are  contracted — they  are  dilated  in  ordinary  optic 
neuritis  and  atrophy  of  the  optic  nerve — and  especially  when  electric- 
like  pains  are  present,  we  have  as  positive  indications  of  the  existence 
of  locomotor  ataxia  as  are  desirable. 

I  tesides  this  atrophy  of  the  optic  nerve,  there  is  another  condition  to 
which  it  is  subject,  as  a  consequence  of  a  preexisting  sclerosis  of  the 
posterior  root-zones,  and  that  is  a  chronic  neuritis.  This  state  is  in- 
duced when  the  spinal  Lesion  is  seated  in  that  part  of  the  cord  known 
as  the  cilio-spinal  centre.     The  ophthalmoscope  in  these  cases  reveals 

•  "Trait6  dea  maladies  du  fond  de  l\jeil,"  Paris,  1870,  p.  7if. 


584  DISEASES  OF  THE  SFIXAL  CORD. 

in  the  early  stages  the  existence  of  choked  disk,  and  subsequently  sim- 
ple atrophic  changes.  This  condition  is  not  peculiar  to  locomotor 
ataxia,  but  may  be  caused  by  other  chronic  affections  of  the  spinal 
cord.  It  is  referred  to  by  Dr.  Clifford  Allbutt '  in  his  excellent  mono- 
graph as  "  simple  or  primary  atrophy  of  the  optic  nerve,  sometimes  ac- 
companied at  first  by  that  slight  hyperemia  and  inactive  proliferation 
which  make  up  the  state  I  have  called  chronic  neuritis.  This  sort  of 
change  I  have  never  found  as  a  result  of  spinal  injuries,  but  I  have 
often  met  with  it  in  chronic  degeneration  of  the  cord,  and  in  locomotor 
ataxy." 

Besides  the  optic,  others  of  the  cerebral  nerves  may  be  affected. 
Those  most  commonly  involved  are  the  third,  the  sixth,  and  the  audi- 
tory; the  lesion  of  this  latter  causing  deafness  and  other  disturbances 
of  hearing. 

The  lesions  found  in  the  brain  never  affect  primarily  the  hemi- 
spheres. To  be  sure,  it  is  sometimes  the  case  that  there  are  mental 
troubles,  but  they  come  on  toward  the  close,  and  are  probably  the 
result  of  defective  nutrition  and  sympathetic  action. 

The  other  cerebral  lesions,  like  that  of  the  optic  nerve,  are  in  very 
intimate  anatomical  relation  with  the  posterior  columns  of  the  cord. 
They  are,  therefore,  met  with  in  the  lower  cerebellar  peduncles,  in  the 
restiform  bodies,  and  in  the  optic  thalami,  and  consist  of  degeneration 
and  atrophy. 

The  situations  of  the  spinal  lesions  and  their  general  character  were 
well  known  to  Romberg  a  before  the  researches  of  Duchenne,  Charcot, 
and  others.  Thus,  he  states  that  he  was  present  at  the  post-mortem 
examination  of  the  cord  of  a  former  patient.  The  organ  was  reduced 
one-third  in  diameter,  and  the  atrophy  was  confined  to  the  lower  part 
of  the  posterior  columns.  The  posterior  nerve-roots  were  also  atro- 
phied, but  the  anterior  columns  were  healthy.  He  was  also  acquainted 
with  the  fact  that  the  cerebral  nerves  were  similarly  affected. 

Although  it  is  probable  that  the  sympathetic  is  atrophied  in  some 
part  of  its  extent,  in  many  cases  of  locomotor  ataxia,  the  fact  has 
not  been  demonstrated,  except  as  regards  one  instance  reported  by 
Donnezan,  in  which  a  filament  from  the  superior  cervical  ganglion  was 
found  atrophied.     The  ganglion  itself  was  healthy. 

In  the  later  stages  of  the  affection  the  muscles  may  exhibit  a  con- 
dition of  atrophy.  In  such  cases  their  tissue  will  be  found  on  micro- 
scopical examination  to  have  undergone  fatty  degeneration  and  substi- 
tution to  a  greater  or  less  extent. 

1  "  On  the  Use  of  the  Ophthalmoscope  in  Diseases  of  the  Nervous  System,"  etc.,  Lon- 
don and  New  York,  1871,  p.  198. 

a"Lehrbuch  der  Nervenkrankheiten  des  Menschen,"  "Sydenham  Society  Transla 
Uon,"  London,  1853,  vol.  ii.,  p.  399. 


PROGRESSIVE   LOCOMOTOR   ATAXIA. 


585 


The  morbid  anatomy  of  the  joint-affections  which  sometimes  result 
from  the  spinal  lesion  consists  in  an  accumulation  of  water  in  the 
synovial  cavity,  and  a  general  oedema  of  the  soft  parts.  The  most 
common  seat  of  this  alteration 


Fig.  70. 


Fig.  77. 


is  the  knee,  and  next  after  that 
the  shoulder.  The  hip,  the  el- 
bow, the  wrist,  and  the  smaller 
joints,  may  also  be  involved. 
Occasionally  the  trouble  does 
not  stop  here,  but  the  articulat- 
ing surfaces  may  become  rough 
from  atrophy  of  the  proper 
bone-tissue,  and  eventually  a 
considerable  part  of  the  osse- 
ous substance  disappears,  giv- 
ing rise  to  spontaneous  laxation. 
The  accompanying  figures,  from 
Charcot,  illustrate  the  nature  of 

the  change.  In  Fig.  76  is  represented  the  superior  extremity  of  the 
healthy  humerus,  and  in  Fig.  77  the  corresponding  part  of  a  humerus 
exhibiting  the  lesions  produced  by  locomotor  ataxia. 

Pathology. — The  theory  of  posterior  spinal  sclerosis  which  is  gen- 
erally held  is,  that  the  lesion  impairs  a  faculty  by  which  the  muscles  are 
brought  into  harmonious  action — a  faculty  of  coordination.  According 
to  this  view,  the  first  thing  to  be  done  was  to  locate  this  faculty  in  an 
organ,  and  Duchenne,  with  whom  it  originated,  adopting  the  ideas  of 
Flourcns  and  others,  placed  it  in  the  cerebellum,  and  therefore  regard- 
ed what  he  designated  progressive  locomotor  ataxia  as  a  disease  of  the 
cerebellum.1  Thus  he  said:  "In  conclusion,  regarding  the  order  of 
appearance,  and  the  habitual  pi*ogress  of  the  symptoms  which  mark 
the  three  periods  of  progressive  locomotor  ataxia,  we  find  that  the 
central  morbid  action  which  produces  the  phenomena  symptomatic  of 
this  disease  begins  in  general  in  the  motor  nerves  of  the  eve,  and  in 
the  tubercular  quadrigemina,  extending  thence  to  the  superior  and 
inferior  cerebellar  peduncles  and  finally  to  the  cerebellum." 

As  already  stated,  Duchenne  has  abandoned  this  view  of  the  loca- 
tion.   But,  although  it  has  been  established  by  numerous  post-mortem 

examinations  thai  the  cerebellum  is  no)  the  seated'  lesion  in  cases  of 
locomotor  ataxia,  ami  although  the  differential  diagnosis  between  dis- 
eases  of  the  cerebellum  and  posterior  spinal  sclerosis  has  been  very 
dearly  made  out,  there  are  some  who  still  hold  the  view  that,  although 
the  cerebellum  shows  m>  traces  of  disease,  and  that,  although  the  poste- 
rior columns  of  the  spinal  cord  may  be  in  a  state  of  BClerosis,  the  symp- 
toms are  the  result  of  an  interruption  to  the  passage,  from  the  cere- 
1  "  he  l'61ectrisatioa  localises,"  deoxteme  Edition,  Paris,  1861,  p,  01 1. 


586  DISEASES   OF   TIIE   SPINAL   CORD. 

bellum  through  the  posterior  columns  to  the  spinal  nerves,  of  that  force 
which  coordinates  the  muscles  into  harmonious  action.  In  the  memoir 
to  which  reference  has  already  been  made,  I  have  entered  at  length 
into  the  consideration  of  the  question  of  the  location  of  a  coordinating 
faculty  in  the  cerebellum,  and  have,  I  think,  adduced  sufficient  facts 
and  arguments  to  show  that  coordination  is  not  one  of  its  functions. 
Without  going  into  a  full  account  of  the  subject,  a  synopsis  of  the  con- 
clusions arrived  at  will  probably  not  be  deemed  out  of  place  : 

1.  The  consequences  of  removal  of  the  cerebellum,  if  the  animal 
survives  the  immediate  effects  of  the  injury,  are  not  enduring.  This 
conclusion  is  supported  by  experiments  by  Flourens,1  Halting,2  Wag- 
ner,8 Dalton,4  myself,8  and  others.  The  physiological  inference,  of 
course,  is,  that,  if  the  faculty  of  coordination  resided  in  the  cerebellum, 
it  ought  to  be  permanently  removed  with  the  ablation  of  the  organ. 

2.  The  entire  removal  of  the  cerebellum  from  some  animals  does 
not  apparently  interfere  in  the  slightest  degree  even  for  a  moment  with 
the  regularity  and  order  of  their  movements.  I  have  performed  a  num- 
ber of  experiments  with  reference  to  this  point,  on  different  classes  of 
animals.  They  prove  very  clearly  that  the  cerebellum  is  not  the  gen- 
erator of  coordinating  power  in  all  animals  that  have  it:  a  fact  in  com- 
parative physiology  which  is  fatal  to  the  hypothesis  that  this  is  its 
function  in  man. 

3.  The  disorder  of  movements  which  results  in  birds  and  mammals 
immediately  after  injury  of  the  cerebellum  is  not  due  to  any  loss  of 
coordinating  power,  but  is  the  result  of  vertigo. 

If  the  cerebellum  be  removed  from  a  pigeon  it  exhibits  disorder  in 
its  movements,  but  a  careful  examination  of  the  phenomena  exhibited, 
shows  that  it  is  suffering  from  a  vertiginous  sensation.  Even  when 
placed  upon  its  breast  and  allowed  to  remain  at  rest,  there  is  a  trem- 
bling and  swaying  of  the  body,  such  as  is  produced  by  alcoholic  in- 
toxication. Exactly  such  symptoms  can  be  caused  by  giving  pigeons 
bread  soaked  in  alcohol. 

4.  The  phenomena  of  cerebellar  disease  or  injury,  as  exhibited  in 
man,  are  not  such  as  show  any  derangement  of  the  coordinating  power. 

Many  cases  are  on  record  which  support  this  proposition.  Andral6 
states  that,  of  ninety-three  cases  of  cerebellar  disease  which  he  has 
studied,  only  one  appeared  to  support  the  theory  which  locates  the  co- 
ordinating power  in  the  cerebellum. 

1  "  Recherches  cxperimentales  sur  les  proprietcs  ct  les  fonctions  tlu  systeme  ner- 
veux,:'  Paris,  1842. 

8  "  Experimenta  qutedam  de  affectibus  laesionum  in  partibus  encephale,"  1826. 

3  "  Nachrichtcn  von  der  Universitat  und  der  Konigl.  Gcsellsehat't  dcr  Wissenschaften 
zu  Gottingcn"  ;  also,  Journal  de  la  physiologic  de  Vhomme  ct  dcs  animaux,  Avril,  1861. 

4  American  Journal  of  the  Medical  Sciences,  January,  1861,  p.  83  ;  also,  "Treatise  on 
Human  Physiology,"  fourth  edition,  1S6Y,  p.  416. 

5  Op.  cit.,  p.  24.  6  "Cliniquc  medieale,"  seconde  edition,  tome  v.,  p.  735. 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  587 

Many  special  instances  might  be  brought  forward,  and  several 
have  occurred  in  my  own  practice.  The  case  of  Alexandrine  Labrosse, 
reported  by  Cornbette,1  is,  however,  worth  referring  to  more  specific- 
ally. His  paper  is  entitled,  "Case  of  a  young  girl  who  died  in  her 
eleventh  year,  in  whom  there  was  complete  absence  of  the  cerebellum, 
of  the  posterior  peduncles,  and  of  the  annular  protuberance."  Magen- 
die  examined  the  brain  after  her  death,  and  satisfied  himself  that  the 
defect  was  congenital.  As  M.  Cornbette  remarks  in  regard  to  this 
case,  Alexandrine  Labrosse  had  been  able  to  walk  for  several  years, 
but  always  in  an  uncertain  manner.  Gradually  her  legs  lost  their 
strength,  and  she  became  paraplegic.  She  preserved  the  use  of  her 
upper  extremities  to  the  last.  It  is  very  evident,  therefore,  that  the 
weakness  of  her  legs  was  due  to  paralysis  ;  for,  had  it  been  the  result 
of  incoordination,  the  arms  must  necessarily  have  participated. 

For  these  reasons,  I  think,  it  cannot  be  considered,  with  any  degree 
of  probability,  that  the  cerebellum  has  anything  whatever  to  do  with 
the  symptoms  manifested  in  sclerosis  of  the  posterior  root-zones  of  the 
cord.  Neither  is  it,  in  my  opinion,  necessary  to  assume  the  existence 
of  an  organ  whose  office  it  is  to  exercise  a  coordinating  power. 

The  incoordination  which  is  so  prominent  a  phenomenon  of  scle- 
rosis of  the  posterior  columns  is  unquestionably  due  to  the  loss  of 
what  is  called  the  muscular  sense. 

Sir  Charles  Bell2  has  argued  strongly  in  support  of  the  existence 
of  such  a  sense.  He  enunciates  his  theory  in  the  following  sentence  : 
"  Between  the  brain  and  the  muscles  there  is  a  circle  of  nerves ;  one 
nerve  conveys  the  influence  from  the  brain  to  the  muscle,  another 
gives  the  sense  of  the  condition  of  the  muscle  to  the  brain." 

It  is  by  this  connection  that  we  are  enabled,  according  to  Sir 
Charles  Bell  and  other  physiologists,  to  form  an  idea  of  the  state  of 
contraction  of  a  muscle,  and  to  lessen  or  increase  the  contraction  as 
may  be  necessary.  In  locomotor  ataxia  the  patient  loses  this  muscu- 
lar sense,  or  is  unable  to  exert  it,  for  the  reason  that  the  posterior 
median  columns  in  lower  levels  of  the  cord,  and  the  median  portion 
of  the  posterior  external  columns  at  a  higher  level,  through  which  the 
muscular  sense-perception  reaches  the  brain,  are  by  disease  rendered 
incapable  of  transmitting  it. 

Before  proceeding  to  the  further  discussion  of  this  subject,  clear 
ideas  should  be  entertained  relative  to  the  anatomy  and  physiology  of 
the  spinal  cord. 

In   Fig.  78,  which  represents  a  transverse  section  through  the  spi- 

1  Journal  de  physiologic  exp&rimentale  et  jmiliohgiquc,  par  F.  Magendie,  tome  xi., 
PnriH,  1831,  p.  'J7. 

*"On  the  Nervous  Circle  which  connects  the  Voluntary  Ifusolca  with  the  Brain," 
Philosophical  Transactions.  Also,  "The  Nervous  System  of  the  Human  Body,"  London, 
1R30,  p.  225. 


588 


DISEASES   OF   THE   SPINAL   CORD. 


Fig 


nal  cord,  the  posterior  nerve-fibres  are  seen  to  enter  the  posterior  horn 
of  gray  matter  and  the  posterior  external  column.  Some  of  these 
fibres  (1  and  2)  connect  directly  with  the  sensory  cells  in  the  posterior 
horn.  These  fibres  probably  conduct  sensory  impressions  of  pain, 
temperature,  and   touch.     Others   (4)   terminate  in   Clark's  columns, 

whence  the 
fibres  spring 
which  form 
the  direct  cer- 
ebellar tract. 
Others,  again 
(3),  which  en- 
ter the  poste- 
rior external 
column,  aft- 
er ascending 
or  descending 
for  a  short 
distance,  en- 
ter the  pos- 
terior medi- 
an column 
and  ascend  to 
the  medulla. 
It  is  through 

this  tract  that  muscular  sense  is  conducted.  Some  (5),  which  enter 
the  posterior  external  column,  pass  directly  over  to  the  motor  cells  on 
the  same  side.  These  fibres  undoubtedly  transmit  the  deep  reflexes. 
The  superficial  reflexes  reach  the  cells  in  the  anterior  horn  through 
the  posterior  horn  (7). 

In  Fig.  79,  which  represents  a  longitudinal  section  of  the  cord, 
the  course  of  the  nerve-fibres  within  the  cord  is  clearly  demonstrated. 
Such  being  the  connection  of  the  posterior  nerve-roots  with  the 
posterior  division  of  the  cord,  it  is  evident  that  no  part  of  the  length 
of  these  columns  can  be  damaged,  either  by  injury  or  disease,  without 
involving  destruction  of  a  corresponding  number  of  nerve-roots,  and, 
as  these  fibres  transmit  all  sensory  impressions,  their  functions  must 
necessarily  be  interfered  with  ;  hence  the  sharp  shooting  pains  from 
irritation  of  the  sensory  roots  ;  the  anaesthesia  from  destruction  of  the 
nerve-fibres  ;  the  inability  to  stand  with  the  eyes  closed,  on  account  of 
the  anaesthesia  of  the  plantar  surface  of  the  feet  and  from  the  loss  of 
the  muscular  sense  ;  and  the  ataxic  gait,  which  is  likewise  due  to  the 
impairment  of  the  muscular  sense  ;  and,  since  reflex  action  depends 
upon  the  preservation  of  the  continuity  of  the  reflex  arc,  the  loss  of 
the  knee-jerk  and  of  other  deep  reflexes  is  readily  explained. 


Diagrammatic  representation  of  the  nerve-fibres  entering  the  cord. 
(Modified  from  Edinger.) 


PROGRESSIVE   LOCOMOTOR   ATAXIA. 


589 


In  sclerosis  of  the  posterior  root-zones  of  the  spinal  cord  the  lesion 
generally  involves  the  posterior  nerve-roots,  the  posterior  white  sub- 
stance, and  the  posterior  cornua  of  gray  substance.  Hence  the  cord 
loses  the  ability  to  transmit  nervous  force.     Those  unconscious  acts 


/rtt 


Diagrammatic  representation  of  the  cour 


tree  in  the  spinal  cord.    (Edinger.) 


of  muscular  coordination  which  are  regulated  by  the  gray  substance 
of  the  spinal  cord  can  no  longer  be  perfectly  accomplished,  and  the 
'train  lb  brought  to  assist  in  the  determination  through  the  sense  of 
Bight.  The  patient  cannot  Btand  well  with  his  eyes  Boat,  or  walk  in 
the  dark,  or  determine  differences  of  weight,  because  he  is  reiving 
altogether  <>n  the  perceptive  faculty  of  the  brain,  and  this  organ  is 
not  in  a  condition  to  perform  its  work  with  precision,  because  Bensorj 


590  DISEASES   OF   THE   SPINAL   CORD. 

impressions  do  not  reach  it  on  account  of  the  destruction  of  the  sen- 
sory pathway  in  the  spinal  cord. 

An  interesting  point  connected  with  the  pathology  of  locomotor 
ataxia  is  the  fact  that  the  spinal  lesions  sometimes  exist  in  conjunc- 
tion with  the  cerebral  lesions  which  are  the  anatomical  basis  of  general 
paralysis  of  the  insane.  This  subject  was  alluded  to  when  the  last- 
named  disease  was  under  consideration.  Westphal,1  who  was  the  first 
to  give  special  attention  to  this  matter,  does  not  believe  that  there  is 
any  direct  relation  between  the  morbid  process  in  the  cord  and  that  in 
the  brain.  Neither  of  them  is,  in  his  opinion,  secondary  to  the  other. 
They  simply  coexist  as  the  expression  of  an  excessive  proclivity  to  dis- 
ease of  the  nervous  system,  just  as  any  other  two  diseases  may  be  pres- 
ent, one  in  the  brain  and  the  other  in  the  cord,  without  there  being  any 
direct  interdependence  between  them.  This  is  undoubtedly  correct. 
Locomotor  ataxia  is  by  no  means  uncommon  in  patients  affected  with 
the  other  forms  of  insanity.  Several  such  cases  have  come  under  my 
own  observation,  and  Dr.  Patrick  Nicol,s  in  an  excellent  memoir,  has 
adduced  several  instances  which  have  occurred  in  his  experience. 

As  we  have  seen,  the  lesions  in  sclerosis  of  the  posterior  root-zones 
are  not  always  confined  to  the  original  seat.  Among  other  parts  of  the 
cord  liable  to  be  involved  is  the  anterior  tract  of  gray  matter.  Hence 
we  have  the  more  complete  development  of  paralysis  and  the  superven- 
tion of  atrophy  in  the  affected  muscles.  A  remarkable  instance  of  loco- 
motor ataxia  combined  with  muscular  atrophy  formed  the  subject  of  a 
clinical  lecture,8  which  I  delivered  at  the  Bellevue  Hospital  Medical 
College,  in  the  winter  of  1871-'72.  In  this  case  there  were  electric-like 
pains,  incoordination,  ocular  troubles,  ptosis,  double  vision,  plantar  an- 
aesthesia, etc.  After  about  two  years  muscular  atrophy  set  in,  begin- 
ning in  the  left  leg,  then  involving  the  right  corresponding  member, 
then  the  left  arm,  and  finally  the  right  upper  extremity. 

In  this  case  the  lesion  of  the  posterior  root-zones  was  the  primary 
lesion,  the  anterior  tract  of  gray  matter  subsequently  becoming  sym- 
metrically implicated.  There  were  no  contractions  like  those  present 
when  the  lateral  columns  of  the  cord  are  the  seat  of  disease. 

In  the  case  of  the  woman  Moli,  reported  by  Pierret,4  to  which  refer- 

1  "  Uebcr  den  gegenwartigen  Standpunktder  Kentnisse  von  der  allgemeinen  progressiven 
Paralyse  der  Irren,"  Griesinger's  Archiv  fur  Psychiatrie  und  Nervenkrankhciten,  Heft 
i.,  Band  i.,  1867. 

i  "  On  Progressive  Locomotor  Ataxy  and  some  other  Forms  of  Locomotor  Deficiency,  as 
found  in  the  Insane,"  "West  Riding  Lunatic  Asylum  Medical  Reports,"  vol.  i.,  18*71,  p. 
1Y8. 

3 '''Clinical  Lectures  on  Diseases  of  the  Nervous  System,"  New  York,  1874,  p. 
156. 

*  "  Sur  les  alt6rations  de  la  substance  grise  de  la  moclle  6piniere  dans  l'ataxie  locomo- 
trice  consider6es  dans  leurs  rapports  avec  l'atrophie  musculaire,"  Archives  de  physiologic, 
1870,  p.  590. 


PROGRESSIVE   LOCOMOTOR   ATAXIA. 


591 


ence  has  already  been  made,  there  were  also  the  combination  of  the 
symptoms  due  to  the  lesion  of  the  posterior  root-zones,  and  those  re- 
sulting from  the  extension  of  the  morbid  process  to  the  anterior  horns 
of  gray  matter — the  right  side  being  the  seat  of  profound  musculai 
atrophy.  On  post-mortem  examination  it  was  found  that  the  right  an- 
terior horn  of  gray  matter  in  the  dorsal  and  cervical  regions  was  the 
seat  of  degenerative  changes  in  the  nerve-cells,  many  of  which  had  dis- 
appeared. The  horn  was  markedly  diminished  in  size.  These  changes 
are  shown  in  the  accompanying  figure  (Fig.  80)  from  Pierret — cr,  the 
posterior  roots  ;  b,  the  internal  radicles,  the  sclerosis  being  limited  to 
their  area  ;  c,  the  right  anterior  horn  of  gray  matter  atrophied.  This 
association  of  muscular  atrophy  with  sclerosis  of  the  posterior  root- 
zones  is  to  be  explained  by  the  fact,  first  pointed  out  by  Kolliker,1  that 
some  of  the  internal  fibres  of  the  posterior  roots  pass  toward  the  ante- 
rior horns  of  gray  matter,  and  can  be  traced  as  far  as  the  large  cells 
forming  the  external  group.  The  connection  of  the  fibres  of  the  pos- 
terior roots  with  the  anterior  horns  of  gray  matter  is  also  referred  to 
by  Lockhart  Clarke  2  and  Gerlach.3 

Fig.  80. 


Treatment. — It  must  be  remembered  that  locomotor  ataxia  often 
spontaneously  remits  in  the  violence  of  its  symptoms.  Indeed,  the  re- 
mission may  at  times  amount  to  almost  a  complete  intermission.  But 
taking  this  fad  into  full  consideration,  I  am  quite  sure  that  the  disease 
is  not  in  every  oas  ■  uninfluenced  by  medical  treatment.  A  great  many 
medicines  have  been  recommended,  and  numbers  of  cures  have  been  re- 
ported.    Careful  inquiry,  however,  suffices  to  show  either  that  the  al- 

1  "A  M.imnil  of  Banian  Histology,"  "Sydenham  Society  Translations,"  vol.  i.,  1853. 
p.  4 in. 

*  *  Philosophical  Transactions,"  1853. 

'Strieker's  "Manual  of  Histology,"  American  edition,  N<w  York,  1878,  p.  645. 


502  DISEASES   OF   TIIE   SPINAL   CORD. 

leged  cures  were  merely  instances  of  more  or  less  complete  remission, 
or  that  the  cases  were  really  not  examples  of  the  disease  in  question. 
To  even  mention  the  assumed  remedies  would  be  profitless  labor. 

In  the  very  earliest  period  of  the  disease  ergot  is  calculated  in  some 
cases  to  be  of  decided  benefit.  It  should  be  administered  in  doses  of 
at  least  a  drachm  three  or  four  times  a  day,  and  continued  for  several 
months.  The  bromide  of  potassium,  sodium,  or  calcium,  is  an  effica- 
cious adjuvant.  Under  the  combined  use  of  these  remedies  I  have 
repeatedly  seen  the  electric-like  pains  diminish  in  violence  or  even 
altogether  disappear.  The  gastric  disturbances  may  often  be  allevi- 
ated by  bismuth,  or,  what  is  usually  still  more  efficacious,  by  Fair- 
child's  pepsin  in  doses  of  three  or  four  grains  with  each  meal. 

With  these  measures  the  primary  galvanic  current  applied  to  the 
spine,  on  each  side  of  the  spinous  processes,  is  an  agent  which  ought 
to  be  used.  Cases  have  been  reported  by  Meyer,  Benedict,  and  others, 
in  which  it  alone  has  apparently  effected  cures — or  arrest  of  the  mor- 
bid process — and  Rosenthal1  speaks  highly  of  its  beneficial  influence. 
I  have  used  it  with  success  in  several  cases  in  conjunction  with  the 
means  previously  mentioned.  Ordinarily,  it  has  not  appeared  to  me 
to  be  of  any  material  service. 

The  pains  in  the  back  and  the  sharp  shooting  pains  in  the  legs  or 
arms  and  around  the  abdominal  and  thoracic  regions  may  be  com- 
bated with  phenacetine  in  ten-  or  twelve-grain  doses,  or  antifebrine  in 
five-grain  doses,  either  of  which  can  be  repeated  in  an  hour  if  neces- 
sary, or  by  codeine  in  doses  of  from  half  a  grain  to  one  or  even  two 
grains,  or  with  hypodermic  injections  of  morphia. 

If  the  case  comes  under  observation  when  the  motorial  troubles  are 
well  marked,  or  if,  after  having  used  it  for  a  month,  no  decidedly 
beneficial  effect  follows  the  treatment  just  specified,  I  omit  the  ergot, 
and  frequently  use  instead,  the  nitrate  of  silver  in  doses  of  the  quarter 
of  a  grain  three  times  a  day.  According  to  Rosenthal,2  Wunderlich, 
Charcot  and  Vulpian,  Herschell,  Klinger,  Duguet  and  Vidal,  have  ex- 
tolled its  merits.  This  remedy  has  in  my  hands  apparently  proved  ser- 
viceable in  several  cases  which  were  well  advanced,  but  I  am  not  able 
to  speak  definitely  on  the  subject,  for  the  reason  that  with  it  bromide 
of  potassium,  and  especially  galvanism,  were  used.  Two  cases  were 
cured  by  the  combined  remedies — one  of  them  was  that  of  a  distin- 
guished journalist,  who,  in  the  first  place,  was  treated  with  ergot,  and 
subsequently,  when  this  medicine  appeared  to  be  of  no  further  effect, 
with  the  nitrate  of  silver.  At  the  present  time,  seven  years  having 
elapsed,  this  gentleman  is  well,  free  from  pains,  able  to  coordinate, 
and  with  no  symptom  of  the  affection  remaining.  The  disease  was  first 
manifested  by  an  epileptic  paroxysm,  and  soon  afterward  ocular  trou- 
bles made  their  appearance.     The  electric-like  pains,  abdominal  con- 

1  "  Klinik  dcr  Ncrvcnkrankheiten,"  Stuttgart,  1875,  p.  394.  2  Op.  tit.,  p.  390. 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  593 

striction,  and  incoordination  in  the  upper  and  lower  extremities,  were 
well  marked.  He  was  under  treatment  for  about  four  months.  The 
other  case  was  that  of  a  lady  of  this  city.  The  disease  in  her  began 
with  pain  in  the  back,  and  electric  pains  in  the  lower  extremities 
Ptosis,  dilatation  of  the  right  pupil,  and  diplopia  followed,  and  then 
gradual  loss  of  sensibility  in  the  soles  of  the  feet,  and  difficulty  in  coor- 
dinating the  muscles  of  the  legs.  The  disease  had  lasted  two  years  and 
a  half  when  the  patient  came  under  my  charge.  She  was  treated  with 
the  nitrate  of  silver  and  the  other  remedies  mentioned,  for  nearly  a 
year,  and  throughout  the  whole  period  gradually  improved  till  her 
recovery  was  complete.  The  nitrate  of  silver  was  suspended  for  a  week 
after  each  month  of  its  administration. 

In  a  third  case  ergot  and  nitrate  of  silver  were  given  together  with- 
out the  bromide  of  potassium.  This  case  was  that  of  a  gentleman,  a 
merchant  of  this  city,  residing  in  Bridgeport,  Connecticut.  He  had  had 
ocular  troubles,  and  was  suffering  from  pains,  incoordination,  plantar 
anaesthesia,  paralysis  of  the  bladder,  and  swelling  of  the  right  knee, 
when  he  came  under  my  charge,  being  sent  to  me  by  my  friend  Dr. 
Hubbard,  of  Bridgeport.  The  disease  had  then  lasted  only  a  few 
months.  With  the  medicines,  the  constant  galvanic  current  to  the 
spine  and  spinal  nerves  was  employed.  He  was  entirely  cured  in  less 
than  three  months, 

In  ail  cases  inquiry  should  be  made  with  reference  to  the  existence 
of  a  syphilitic  taint.  If  affirmative  results  follow  the  investigation,  the 
iodide  of  potassium  should  be  administered  in  gradually-increasing  doses 
as  recommended  for  acute  spinal  meningitis,  or  in  combination  with 
corrosive  sublimate,  according  to  the  formula  given  on  page  308,  recol- 
lecting that  galvanism  is  likewise  to  be  used,  and  such  other  treatment 
as  the  special  symptoms  may  seem  to  require.  Two  cases  were  cured 
by  this  treatment;  one  of  them  was  that  of  a  gentleman  from  the  West 
— a  fully-developed  case — who  had  been  treated  by  my  friend  Dr. 
Bumstead,  for  other  syphilitic  troubles,  and  who  sent  him  to  me  for  his 
spinal  disease.  The  incoordination,  plantar  anaesthesia,  pain  in  the 
lumbar  region,  and  the  electric  pains,  were  all  present,  together  with 
slight  diplopia.  He  was  under  treatment  for  about  ten  months.  I  met 
him  a  few  weeks  since  in  a  railway-car,  the  picture  of  health,  and,  as  he 
told  me,  perfectly  well. 

The  other  case  occurred  in  the  person  of  a  gentleman  of  this  city, 
and  was  similar  in  general  features  to  the  preceding.  A  cure  was  ob- 
tained, after  like  medication,  in  six  months. 

In  the  majority  of  eases,  whether  there  is  a  \\  philitic  taint  or  not, 

I   administer  the   iodide  of   potassium.      Beginning   with   moderate 

doses,  ii  should  be  gradually  increased  up  to  the  poinl  of  toleration, 

which  differs  vastly  iii  different  individual-.     The  iodide  of  potassium 

ry  efficaoious  in  preventing  the  formation  of  new  connective  tis- 

89 


594  DISEASES  OF  THE   SPINAL   CORD. 

sue.  Jn  this  manner,  I  am.  convinced,  the  progress  of  the  disease  is 
often  arrested,  and  in  the  early  stage,  which  is  probably  one  of  simple 
congestion  only,  destruction  of  the  nerve-fibres  may  be  avoided. 

In  another  case,  after  ergot  had  been  used  for  several  months  with- 
out apparent  benefit,  the  nitrate  of  silver  was  administered  with  the 
effect,  to  all  appearance,  of  checking  the  further  progress  of  the  disease, 
and  producing  decided  amelioration  of  the  existing  symptoms.  The 
patient,  a  distinguished  member  of  the  dramatic  profession,  by  my  ad- 
vice withdrew  from  the  stage,  and,  being  in  Philadelphia,  he  consulted 
at  my  suggestion  Dr.  Weir  Mitchell,  who  unhesitatingly  confirmed  my 
diagnosis.  He  took  the  nitrate  persistently  for  about  six  months,  and 
was  so  greatly  improved  that  I  gave  my  consent  to  his  resuming  his 
profession.  There  are  now  no  pains;  his  coordination  is  good,  and  his 
general  health  leaves  nothing  to  be  desired. 

In  several  cases  I  have  obtained  ameliorations  by  the  use  of  phos- 
phoric acid,  phosphorus,  and  chloride  of  barium,  but  after  extensive 
experience  with  these  agents,  I  am  unable  to  report  any  permanently 
good  results. 

If  the  vesical  sphincter  be  paralyzed,  belladonna  may  be  used  with 
advantage,  preferably  in  the  form  of  hypodermic  injections  of  atropia 
gradually  increased  daily,  from  the  one  hundred  and  twentieth  of  a 
grain  to  the  thirtieth. 

Hydro-therapeutics  in  all  forms,  and  faradization,  have  never,  ac- 
cording to  my  experience,  been  of  the  slightest  benefit,  except  as  re- 
gards the  use  of  the  latter  to  the  affected  muscles.  The  ether-spray 
recommended  by  Jaccoud  has  been  entirely  inefficacious  in  my  hands, 
and  the  same  may  be  said  of  all  plasters  and  embrocations. 

One  auxiliary  means  of  treatment  I  have  lately  employed  with  ad- 
vantage, and  that  is,  keeping  the  patient  as  much  as  possible  from 
using  the  groups  of  muscles  which  have  lost  their  coordinating  power, 
and  requiring  him,  when  he  walks,  to  employ  crutches  to  assist  him, 
By  systematical^  carrying  out  this  plan  the  nervous  force  of  the  pa- 
tient is  not  wasted,  and  a  diseased  organ,  such  as  is  his  spinal  cord,  is 
not  overtasked. 

Lately  I  have  employed,  and  thus  far  with  apparently  good  re- 
sults, the  actual  cautery  to  the  spinal  column.  I  have  used  it  in  a 
great  number  of  cases.  The  effect  has  been  to  lessen,  and  in  many 
cases  entirely  to  abolish,  the  electric  pains  and  the  feeling  of  con- 
striction around  the  body.  In  one  fully-developed  case  which  I 
had  before  the  medical  class  of  the  University  of  New  York,  the 
pains,  which  were  of  great  intensity,  ceased  within  a  few  hours  after 
the  first  cauterization.  Ten  days  subsequently  I  repeated  the  oper- 
ation, the  pains  in  the  legs  having  returned,  and  again  the  relief  was 
complete. 

Nerve-stretching  is  a  therapeutical  measure  of  some  importance. 


PROGRESSIVE   LOCOMOTOR   ATAXIA.  595 

Langenbeck1  was  the  first  to  perform  this  operation  for  locomotor 
ataxia,  and  the  results,  not  only  in  relieving  the  electric-like  pains  for 
which  the  operation  was  performed,  but  in  curing  the  ataxia,  were 
such  as  to  astonish  the  operator.  For  a  short  time  afterward  the 
reports  of  cases  cured  by  this  means  were  numerous.  Certainly  noth- 
ing in  the  whole  range  of  neuro-therapy  is  so  contrary  to  our  precon- 
ceived opinions  as  to  suppose  for  one  instant  that  stretching  the  sci- 
atic nerves  will  have  any  influence  in  restoring  sclerosed  nerve-tissue 
to  a  normal  condition.  In  time  nerve-stretching  was  relegated  to  its 
proper  place  as  a  therapeutic  measure.  Sometimes  the  pains  in  the 
affected  limbs  are  so  severe  that  the  ordinary  forms  of  treatment  are 
not  adequate  for  their  relief,  and  the  patient  gradually  becomes  ex- 
hausted from  suffering  and  from  loss  of  sleep.  In  such  a  case  stretch- 
ing the  sciatic  nerves  invariably  puts  an  end  to  the  suffering,  some- 
times for  several  weeks  and  again  for  several  months,  and  when  the 
pain  does  return  it  is  frequently  of  a  more  subdued  character.  The 
operation  is  simple,  and  free  from  danger.  An  incision  should  be 
made  in  the  mesial  line  of  the  integument  on  the  posterior  surface  of 
the  thigh  just  above  the  popliteal  space.  On  separating  the  biceps 
from  the  semitendinosus,  the  sciatic  nerve  will  be  readily  discovered. 
If  the  little  finger  is  then  passed  under  the  nerve,  the  latter  can  be 
stretched  to  the  desired  extent. 

The  treatment  of  ataxia  by  suspension  has  recently  attracted  con- 
siderable attention.  It  was  first  practiced  by  Dr.  Motchoukowski,  of 
Odessa,  Russia,  as  far  back  as  1883,  but  attracted  no  attention  from 
the  medical  profession  until  Charcot2  published  his  article  attesting 
to  its  efficiency  as  a  therapeutic  agent.  Since  then  numerous  cases  of 
ataxia  have  been  reported  to  have  been  cured  by  this  means  ;  but, 
though  my  experience  with  this  method  of  treatment  has  been  exten- 
sive, I  cannot  say  that  I  have  ever  seen  a  single  case  of  genuine  tabes 
in  which  suspension  alone  has  arrested  the  progress  of  the  disease. 
That  it  is  of  material  assistance  in  relieving  some  of  the  symptoms  of 
tabes  in  the  majority  of  cases  is  beyond  the  shadow  of  a  doubt ;  but 
it  has  also  been  shown  that  in  a  small  proportion  of  cases  the  symp- 
toms are  aggravated  with  each  successive  suspension. 

The  modifications  most  liable  to  occur  from  suspension  are  :  an 
improvement  in  the  coordinating  powers,  thereby  enabling  the  patient 
to  stand  and  to  walk  better;  an  amelioration  in  the  sharp,  shooting 
pains  in  the  affected  extremities;  ami  an  abatement  <>i"  the  gastric 
rriscs.  The  difficulty  of  retaining  or  of  passing  the  urine  often  ceases, 
ami    i  lie   sexual    power,   which    is   frequently    weakened,    i^  sometimes 

restored.  Improvement  from  suspension  is  not  apparent  from  the 
first.  Usually  from  ten  to  fifteen  or  more  suspensions  are  necessary 
before  decided  benefit  is  manifested. 

1  Berliner  Win.  Wochcmchrift,  No.  48,  1879.  *  Le  prog,  mid.,  Jim.  19,  1889. 


596 


DISEASES  OF  THE  SPINAL  CORD. 


The  best  suspension  apparatus,  to  my  mind,  is  one  by  which  the 
traction  is  borne  by  the  occiput  and  chin,  the  axillary  supports  not 
being  used  at  all.  The  apparatus  should  be  hung  on  a  weight  scales, 
so  that  the  exact  amount  of  traction  exerted  can  be  known  and  noted. 
The  accompanying  illustration  (Fig.  81),  made  from  a  photograph, 


F:g.  81. 


gives  an  excellent  representation  of  the  apparatus  as  I  first  used  it. 
Since  then,  however,  the  interposition  of  a  weight-scales  between  the 
head-gear  and  the  pulley-ropes,  and  the  abolition  of  the  axillary  sup- 
ports, make  the  instrument  much  more  scientific  and  exact.  At  first 
the  traction  should  not  exceed  seventy-five  pounds,  and  should  be 
gradually  increased  with  each  suspension,  until  the  limit  of  one  hun- 
dred and  twenty  or  one  hundred  and  thirty  pounds  is  reached.    In  the 


INFLAMMATION   OF   THE   COLUMNS   OF   GOLL.  597 

beginning  the  suspensions  should  not  last  longer  than  half  a  minute, 
but  should  be  extended  gradually  up  to  two  minutes. 

Judging  from  my  own  experience,  and  considering  the  experience 
of  others  who  have  used  suspension  properly,  I  cannot  help  being 
satisfied  with  the  results  obtained.  Beneficial  effects  are  more  likely 
to  follow  in  cases  of  incipient  tabes  than  in  those  of  longer  duration, 
in  which  destruction  of  the  nerve-fibres  has  taken  place  to  a  consider- 
able extent.  In  three  cases  of  functional  impotence  decided  evidence 
of  amelioration  was  shown  after  three  suspensions. 

Suspension  is  contra-indicated  where  tabes  coexists  with  valvular 
cardiac  disease,  phthisis,  and  extreme  anaemia. 

IX. 

INFLAMMATION — SCLEROSIS — OF   THE    COLUMNS    OF   GOLL. 

We  have  seen  that  the  columns  of  Goll  or  posterior  median  fasciculi 
are  generally  the  seat  of  a  lesion  simultaneously  with,  or  more  probably 
secondarily  to,  that  which,  existing  in  the  posterior  root-zones,  causes 
the  group  of  symptoms  we  call  locomotor  ataxia. 

There  is,  however,  no  doubt  that  they  may  be  the  seat  of  primary 
disease,  and,  though  the  data  are  not  yet  sufficient  to  enable  us  to  give 
the  clinical  history  of  the  affection  as  fully  as  is  desirable,  we  are  not 
altogether  without  information  on  the  subject.  Our  definite  knowledge 
rests  upon  one  case  reported  in  full  by  Pierret,1  and  which  I  quote, 
greatly  condensed  as  follows  : 

Catherine  Magnaigat,  when  thirty  years  of  age  (1855),  experienced 
numbness,  "  pins  and  needles,"  sensations  of  heat,  and  deep-seated  pains 
in  the  extremities,  especially  the  upper.  There  were  also  pains  in  the 
loins,  obstinate  headache,  and  a  sense  of  tightness  around  the  chest. 

In  18G0,  vertigo  and  weakness  of  the  lower  extremities  super- 
vened. She  did  not  distinctly  feel  the  ground  with  her  feet,  and  she 
was  obliged  to  walk  with  a  cane. 

In  180)3  she  entered  the  Salpetriere,  and  came  under  M.  Charcot's 
care.     Her  condition  was  then  as  follows  : 

Tactile  sensibility  was  diminished  in  the  soles  of  the  feet,  the  left 
especially.  She  could  not  walk  without  a  crutch,  which  she  used  under 
her  right  arm.  \\ 'hen  she  wished  to  go  forward  she  experienced  an 
impulse  to  spring  or  leap,  and  finally  she  advanced  by  a  series  of  short 
steps,  and  felt  as  if  impelled  by  a  force  she  could  not  resist.  When  she 
closed  her  eyes  while  standing  alone  she  maintained  the  erect  position 
for  a  while,  but  would  eventually  have  fallen  unless  supported.  She 
was  easily  fatigued,  and  walking  caused  pains  which  compelled  her  soon 
to  stop.    Her  feet  seemed  to  stick  to  the  ground  when  she  mule  volun- 

1  "Notes  sur  mi  cm  de  Bol6rose  primitive  da  tYisecau  m<5ir.an  des  cordons  post6- 
ricurs,"  Archives  d»  ohyriologie,  1878,  p.  71. 


598 


DISEASES  OF   THE   SPINAL   CORD. 


tary  efforts  to  lift  them.  Sometimes,  when  she  attempted  to  advance, 
she  felt  herself  irresistibly  drawn  toward  the  left  side.  When  after 
having  taken  a  few  steps  she  wished  to  go  back,  she  turned  round 
suddenly,  as  if  moved  by  a  spring.  In  1806  she  for  the  first  time  ex- 
perienced constricting  pains  around  the  body  low  down,  and  electric- 
like  in  character.  Soon  afterward  she  felt  similar  pains  in  the  anterior 
part  of  the  thighs.  Cutaneous  sensibility  was  then  diminished  in  the 
lower  extremities.  The  idea  of  the  exact  position  of  the  limbs  was 
not  in  the  least  impaired,  and  there  wras  no  incoordination.  Such  was 
her  condition  when  in  1871  she  died  of  pneumonia. 

The  post-mortem  examination  showed  that  the  columns  of  Goll 
were  throughout  their  whole  extent  in  a  state  of  sclerosis.  It  was 
most  manifest  in  the  dorsal  region,  where  it  to  a  slight  extent  invaded 
the  posterior  root-zones,  to  which  circumstance,  doubtless,  the  electric- 
like  pains  experienced  by  the  patient  were  due. 

The  case  would  appear  to  show  that  sclerosis  of  the  columns  of 
Goll  gives  rise  to  certain  symptoms  in  the  lower  extremities,  however 
much  the  superior  may  retain  their  normal  condition.  In  some  cases 
of  locomotor  ataxia  there  has  been  noticed  an  unusual  feeling  of 
heaviness  in  the  lower  extremities,  or  a  marked  tendency  to  go  back- 
ward, or  a  great  feeling  of  fatigue  after 
slight  exertion,  a  marked  incertitude  in 
standing  erect,  or  even  an  irresistible  feel- 
ing of  propulsion.  In  such  instances,  there- 
fore, the  columns  of  Goll  were  affected  at 
the  same  time  with  the  posterior  root-zones. 
M.  Pierret  holds  the  opinion  that  these  col- 
umns, to  some  extent,  preside  over  motion. 
Figs.  82,  83,  84,  and  85  represent  scle- 
rosis limited  to  the  columns  of  Goll,  and 
are  taken  from  M.  Pierret's  memoir.    Fig. 


Fig.  83. 


Fib.  84. 


Fig.  85. 


82  refers  to  the  cervical  region,  Fig.  83  to  the  dorsal.  Fig.  84  shows 
the  appearance  of  a  section  made  at  the  level  of  the  second  dorsal 
vertebra,  and  Fig.  85  one  taken  from  the  upper  part  of  the  lumbar 
enlargement.    The  sclerosed  portion  is  represented  at  a  in  each  figure. 


DISSEMINATED   INFLAMMATION*   OF   TEE   SPINAL   CORD.  599 

In  the  present  state  of  our  knowledge,  all  that  we  can  do  is  to  await 
further  developments  relative  to  the  interesting  points  raised  by  the 
case  which  M.  Pierret  has  so  well  studied. 

X. 

DISSEMINATED    INFLAMMATION    OF   THE    SPINAL    CORD MULTIPLE    SPINAL 

SCLEROSIS SCLEROSIS    IX    PLATES INSULAR   SCLEROSIS. 

Thus  far  we  have  considered  the  inflammatory  affections  of  the 
spinal  cord  as  they  appear  in  one  or  another  of  the  anatomical  divisions 
which  make  up  that  nerve-centre.  But  we  have  now  to  engage  our- 
selves with  a  lesion  which  has  no  fixed  habitation,  which  is  met  with  in 
the  gray  and  white  matter  indiscriminately,  and  which  occurs  in  distinct 
foci,  patches,  plates,  or  islets,  in  various  parts  at  the  same  time  or  con- 
secutively. This  is  what  is  known  as  multiple  spinal  sclerosis  or 
sclerosis  in  disseminated  plates — the  sclerose  en  plaques  disskmin&es  of 
Charcot. 

Symptoms. — Multiple  spinal  sclerosis  generally  first  manifests  its 
presence  by  more  or  less  weakness  in  one  or  the  other  lower  extremity. 
Before  long  the  corresponding  limb  becomes  involved;  and,  eventually, 
if  the  disorder  continues  to  form  additional  centres  of  morbid  action, 
the  upper  extremities  are  successively  attacked. 

At  other  times  the  first  symptoms  are  connected  with  sensibility,  and 
consist  of  the  various  sensations  of  numbness,  tingling,  "pins  and 
needles,"  formication,  and  the  like.  Or  these  phenomena  may  make  their 
appearance  simultaneously  with  the  paresis.  The  gait  of  a  person 
affected  with  multiple  spinal  sclerosis  is  uncertain  and  titubating — like 
that  of  an  individual  slightly  intoxicated.  Although  there  is  defective 
coordination,  the  patient  stands  as  well  with  the  eyes  shut  as  open,  and 
has  no  additional  difficulty  in  walking  in  the  dark  or  with  the  eyes 
closed. 

The  paralysis  advances,  but  there  are  no  marked  disturbances  of 
sensibility,  and  the  numbness  which  may  have  been  present  to  some 
extent  in  the  early  stage  usually  disappears.  The  patient  is,  therefore, 
sensitive  to  changes  of  temperature,  to  pain,  and  to  pressure.  Pains 
are  very  uncommon.  Occasionally,  there  arc  slight  painful  sensations 
in  the  paralyzed  parts,  but  they  are  temporary. 

The  general  health  usually  remains  good,  and  the  mind  is  unaf- 
fected. 

Later,  in  the  course  of  the  disease,  rigidity  or  contraction  makes  its 
appearance  in  the  paralyzed  limbs,  or  both  these  conditions  may  co- 
exist in  the  same  extremity,  some  of  the  joints  being  contracted,  and 
others  rigidly  <\tenled.  The  tendency  is  for  these  conditions  to  be- 
come permanent.  Again,  there  are  violent  tonic  convulsions  in  the 
paralyzed   limbs  which  may  bo  spontaneous,  but  which  are    readily  e\- 


600  DISEASES   OF   THE   SPINAL   CORD. 

cited  by  impressions  made  upon  the  skin  of  the  affected  extremities,  or 
even  sometimes  by  mental  emotions.  They  may  precede,  or  coexist 
with,  or  follow  the  permanent  contractions. 

In  some  instances  these  phenomena  are  not  met  "with.  They  were 
absent  in  the  case  of  Dr.  Pennock,  reported  by  Drs.  Morris  and  Mitchell; 
in  a  case  under  my  own  charge,  and  in  which  I  made  an  examination  of 
the  cord  soon  after  death  ;  and  in  a  case  reported  by  Friedreich,1  in 
which  multiple  spinal  sclerosis  existed  in  conjunction  with  the  lesions 
of  locomotor  ataxia. 

When  present,  as  they  generally  are,  these  permanant  contractions 
of  the  muscles  exhibit  different  phases  in  the  upper  and  lower  extremi- 
ties. In  the  former  the  flexors  predominate  over  the  extensors,  while  in 
the  latter  the  extensors  prevail.  The  spasmodic  tonic  convulsive  move- 
ments of  the  limbs  are  especially  met  with  in  the  lower  extremities,  the 
upper  being  rarely  their  seat. 

After  a  time,  which  may  vary  from  three  or  four  to  fifteen  or  twenty 
or  even  more  years,  the  limbs  become  almost  entirely  paralyzed,  and 
the  contraction  and  rigidity  are  still  more  strongly  marked.  Whatever 
voluntary  movements  the  patient  is  capable  of  executing  now  cause 
pains  in  the  parts.  The  sensibility  usually,  however,  even  at  this  period 
remains  but  little  affected.  Reflex  excitability  generally  exists  though 
perhaps  slightly  impaired  ;  sometimes  it  is  altogether  lost,  and  again 
it  may  be  greatly  exaggerated.  The  bladder  and  the  sphincter  ani 
retain  their  power  to  the  last.  Bed-sores  form  on  the  parts  subjected 
to  pressure  as  the  patient  lies  in  bed,  and  death  eventually  ensues, 
either  from  exhaustion  or  from  some  intercurrent  affection. 

Such  is  a  description  of  multiple  spinal  sclerosis  as  it  is  ordinarily  en- 
countered— and  it  must  be  confessed  that  the  clinical  features  are  not 
very  striking  or  peculiar.  But  even  this  type,  imperfect  as  it  is,  is  sub- 
ject to  great  diversities.  Sometimes  there  are  violent  pains  of  an  elec- 
tric-like character  simulating  those  which  are  so  prominent  a  feature  of 
locomotor  ataxia  and  like  them  resulting  from  the  implication  of  the 
posterior  root-zones  in  the  lesion.  Sometimes  the  superior  extremities 
are  attacked  first.  Again,  anaesthesia  constitutes  a  prominent  feature, 
and  the  phenomena  ordinarily  present  may  be  more  or  less  modified  in 
extent  and  intensity  in  different  cases. 

In  their  very  excellent  monograph  on  the  subject,  MM.  Bourneville 
and  Guerard,3  in  detailing  the  symptomatology  of  the  spinal  form  of 
disseminated  sclerosis,  say: 

"  After  a  variable  time  the  superior  and  inferior  extremities  become 
the  seat  of  rhythmical    agitations,  which  are  only  present,  however, 

1  "Ueber  degenerative  Atrophic  der  spinalen  Hinterstrange,"  Archiv  fi'ir  pathologischt 
Anatomie  und  Physiologie,  18G3,  p.  433. 

8  "  De  la  sclerose  en  plaques  dissemin<5es,"  Paris,  1869,  p.  61. 


DISSEMINATED   INFLAMMATION   OF   THE   SPINAL   CORD.  601 

when  spontaneous  or  voluntary  movements  are  made.  In  the  state  of 
repose  the  members  are  not  affected  with  any  tremor." 

in  this  connection  I  desire  to  repeat  what  I  wrote  five  years  ago,1 
that  "  tremor  is  never  observed  in  spinal  sclerosis  of  any  form,  diffused, 
multiple,  or  cortical,  unless  the  pons  Varolii  or  superior  ganglia  of  the 
brain  are  implicated.  In  the  only  case  of  this  latter  form  published — 
that  of  Yulpian  s — the  sclerosis  extended  throughout  the  whole  length 
of  the  cord,  and  likewise  involved  the  pons  Varolii,  cerebellar  peduncles, 
and  other  intra-cranial  organs,  besides  being  accompanied  with  well- 
marked  spinal  meningitis.  The  tremor  observed  at  a  late  period  of  the 
disease  cannot,  therefore,  be  ascribed  to  the  lesion  of  the  cord  below  the 
medulla  oblongata." 

Of  the  cases  cited  by  Bourneville  and  Guerard  in  which  post-mortem 
examinations  were  made,  one  from  Vulpian  and  one  from  Morris  and 
Mitchell,  in  which  the  lesions  were  restricted  to  the  cord,  there  was  no 
tremor  at  any  time  in  the  course  of  the  disease;  and  in  a  case  of  my  own 
already  cited,  and  which  will  be  still  more  specifically  referred  to  here- 
after, in  which  the  cord  was  the  seat  of  several  islets  of  sclerosed  tissue, 
tremor  had  never  been  a  feature  of  the  symptomatology. 

As  we  shall  see  hereafter,  when  we  come  to  the  consideration  of  the 
cerebro-spinal  form  of  the  disease — multiple  cerebro-spinal  sclerosis — 
tremor  constitutes  one  of  the  most  prominent  phenomena  of  the  affec- 
tion. We  have  already  seen  that  it  is  a  marked  symptom  of  the  purely 
cerebral  type  of  the  affection.  I  am  quite  sure,  however,  that  in  the 
disease  we  are  now  considering,  restricted  as  its  lesions  are  to  the 
spinal  cord,  rhythmical  tremor  is  not  encountered. 

Causes. — The  causes  of  multiple  spinal  sclerosis  are  not  well  under- 
stood. In  a  case  fully  reported  by  Vulpian,3  the  affection  appeared  to 
have  been  induced  by  a  sprain  of  the  left  ankle.  The  extremity  re- 
mained weak-,  and  three  years  afterward  the  patient  had  a  fall,  and 
then  the  right  lower  extremity  became  weak  and  subsequently  the 
right  upper  extremity.  The  left  upper  extremity  was  not  affected 
for  several  years. 

In  the  case  of  Dr.  Pennock,  reported  by  Drs.  Morris  and  Mitchell, 
the  disease  began  while  the  patient  was  busily  engaged  in  professional 
studies. 

In  the  case  in  which  I  verified  the  existence  of  the  disease  by  post- 
mortem examination,  it  was  apparently  caused  by  exposure  to  cold  and 
dampness. 

Jt  is  probable  thai  blows  on  the  spine,  concussions — such  as  are  pro- 
duced by  railway  accidents — and  the  gouty  and  syphilitic  diatheses — 

1  First  and  Bubaequent  editions  of  this  work,  p,  '173. 
1  Op.  c(/.,  p.  64,  <i  uq. 

5  "Note  sur  la  bcI&om  i.!i  plnqucs  de  la  moSlle  eplnlere,"  Union  midicah,  i860,  Juin 
7.  9,  14,  et  19,  Obi.  i. 


602  DISEASES  OF  THE  SPINAL  COED. 

may  induce  multiple  spinal  sclerosis.  There  is  in  reality  no  reason,  to 
my  mind,  why  all  the  influences  which  are  capable  of  causing  the  dif- 
fused forms  of  sclerosis  which  have  been  considered,  may  not  also 
cause  the  disseminated  variety.  But  it  is  difficult  to  arrive  at  any 
definite  information  relative  to  this  matter,  so  long  as  the  clinical 
features  of  the  disease  are  so  little  characteristic. 

Diagnosis. — There  is  very  little  in  multiple  spinal  sclerosis  sufficient- 
ly pathognomonic  to  aid  us  in  our  diagnosis  of  the  affection.  The 
symptoms  in  some  cases  are  identical  with  those  of  spastic  spinal  paral- 
ysis ;  in  others  they  resemble  those  of  locomotor  ataxia,  as  in  the  two 
cases  reported  by  Friedreich,  to  one  of  which  allusion  has  already  been 
made.  In  the  present  state  of  our  knowledge,  therefore,  I  am  afraid 
we  must  wait  for  the  scalpel  and  the  microscope  to  determine  with  any 
degree  of  accuracy  the  diagnosis  of  multiple  spinal  sclerosis. 

Prognosis. — The  disease  is  not  one  which  is  directly  calculated  to 
cause  death.  All  the  patients  known  to  have  died  while  subject  to  it, 
succumbed  to  some  intercurrent  affection,  such  as  bronchitis,  dysentery, 
typhoid  fever,  and  pneumonia.  It  undoubtedly  tends  to  weaken  the 
vital  powers,  and  hence  is  indirectly  the  cause  of  a  fatal  result.  So  far 
as  any  prospect  of  arresting,  by  therapeutic  means,  the  tendency  to  the 
formation  of  other  islets  of  inflammation  and  sclerosis,  or  of  restoring 
the  integrity  of  the  cord  is  concerned,  there  does  not  appear  to  be  much 
hope.  For,  though  its  progress  is  in  many  cases  slow,  and  in  others 
seems,  at  times,  to  be  self -limited,  it  pursues  its  course  unamenable,  so 
far  as  we  know,  to  medical  treatment.  In  the  diffused  forms  of  spinal 
sclerosis  there  is  but  one  centre  of  morbid  action  ;  in  the  disseminated 
there  are  several,  which,  if  not  coexistent,  tend,  through  an  inherent 
proclivity,  to  be  produced  indefinitely.  To  this  circumstance  is  due  the 
fact  that  the  prognosis  of  the  disease  under  consideration  is  more  un- 
favorable than  that  of  sclerosis  of  the  posterior  root-zones  or  even  sym- 
metrical lateral  sclerosis. 

Morbid  Anatomy  and  Pathology. — Multiple  spinal  sclerosis  consists 
in  the  dissemination  through  the  cord  of  masses  of  sclerosed  tissue, 
which  have  resulted  from  the  proliferation  of  the  neuroglia  and  the 
consequent  atrophy  and  disappearance  of  the  proper  nerve-elements. 
They  are  of  a  gray  color,  of  increased  consistence,  of  irregular  size  and 
form,  and  may  exist  in  any  part  of  either  the  gray  or  white  tissue  of 
the  cord  ;  often,  however,  manifesting  a  tendency  to  involve  the  two 
lateral  halves  of  the  cord  symmetrically. 

In  the  case  reported  by  Vulpian,  the  volume  of  the  cord  was  evi- 
dently diminished,  and  on  different  points  of  its  surface  exhibited  an 
ashy-gray  coloration.  The  antero-posterior  diameter  of  the  cord  was 
markedly  lessened  at  those  places  where  the  islets  of  sclerosed  tissue 
existed. 

In  this  case  there  had  been  progressive  paresis,  rigidity,  and  con 


DISSEMINATED   INFLAMMATION   OF   THE   SPINAL   CORD.  603 

fraction,  with  extension  of  all  four  limbs,  without  tremor  of  any  kind. 
The  alterations  were  found  in  the  anterior,  lateral,  and  posterior  col- 
umns, and  in  the  anterior  and  posterior  horns  of  gray  matter. 

In  the  case  of  Dr.  Pennock,  reported  by  Drs.  Morris  and  S.  "Weir 
Mitchell,1  the  sclerosed  tissue  was  confined  mainly  to  the  lateral  col- 
umns. The  posterior  were  involved  to  a  very  small  extent.  In  this 
case  there  were  partial  anaesthesia,  gradually-advancing  paralysis  im- 
plicating all  four  extremities,  and  paralysis  of  the  bladder.  The  intel- 
lectual faculties  were  never  affected  in  the  least.  The  course  of  the 
disease  was  progressively  onward,  and,  though  there  was  toward  the 
last  a  total  loss  of  voluntary  power  below  the  neck,  reflex  action  re- 
mained unaffected.  There  were  no  tremors  with  or  without  voluntary 
movements.  In  regard  to  this  case,  Dr.  Mitchell,  who  made  the  micro- 
scopical examination,  remarks  that  there  were  : 

"1.  Integrity  of  mental  and  moral  manifestations. 

"  2.  Absolute  loss  of  voluntary  motive  power  below  the  head,  or 
rather  below  the  neck. 

"  3.  Sensation  nearly  perfect. 

"4.  Respiration  good  ;  reflex  motion  preserved  and  exhibited  in  the 
form  of  spasm  or  irritation  of  certain  parts  of  the  skin." 

All  of  which  are  what  we  should  expect  to  find  in  sclerosis  almost, 
entirely  confined  to  the  lateral  pyramidal  tract. 

In  the  case  which  I  have  mentioned  as  coming  under  my  own  obser- 
vation, the  patient,  J.  H.,  consulted  me  in  the  winter  of  1869-'70.  He 
was  then  unable  to  walk  without  a  cane  and  the  assistance  of  an  attend- 
ant. He  had  previously  been  treated  at  a  water-cure  establishment, 
and  more  recently  by  the  Swedish  movement-cure,  and  of  course  with- 
out benefit.  The  symptoms  were  mainly  connected  with  motility. 
Both  lower  extremities  were  paralyzed  ;  the  bladder  was  inactive,  but 
not  the  sphincter,  and  there  was  obstinate  constipation.  There  were 
occasional  fibrillary  contractions  of  the  paralyzed  muscles,  and  at  times 
pain  in  the  back  and  limbs — never,  however,  of  any  great  degree  of 
severity.  There  were  no  tremcrs,  either  with  or  without  voluntary 
motions. 

The  patient  obtained  very  little  benefit  from  tin'  treatment  to  which 
I  subjected  him,  and  I  advised  him  to  return  to  his  home  in  Ohio.  A 
few  months  afterward,  he  died. 

The  dorsal,  lumbar,  and  sacral  regions  of  the  cord  were  sent  to  me 
for  examination  by  his  physicians,  Drs.  Ramsey  and  Bishop,  of  Delhi, 
Ohio.  In  a  letter,  the  latter  Informed  me  thai  tin- vessels  of  the  pia 
mater  were  injected. 

The  cord  arrived  in  good  condition,  having  been  carefully  preserved 
in  strong  alcohol.     Upon  inspection,  the  antero-lateral  columns  in  the 

1  American  Journal  of  On   Mtdieal  Sciences,  July,  1868. 


004  DISEASES   OF   THE   SPINAL   CORD. 

middle  and  lower  dorsal  regions  to  the  extent  of  three  and  a  half 
inches  were  seen  to  be  of  a  grayish  tint,  which  became  deeper  in  shade 
from  above  downward.  Below  this,  at  the  junction  of  the  dorsal  with 
the  lumbar  portion,  was  another  patch  two  and  a  half  inches  in  length, 
and  also  involving  the  whole  superficies  of  the  antero-lateral  columns  ; 
and,  separated  from  this  by  a  portion  of  apparently  healthy  tissue,  was 
another  discolored,  irregular  patch,  an  inch  and  a  half  in  length,  along 
the  left  antero-lateral  column  ;  and,  below  this,  a  similar  tract,  two 
inches  and  an  eighth  long,  involving  the  right  antero-lateral  column. 
The  difference  in  consistence  between  these  patches  and  the  other  parts 
of  the  cord  was  very  decided,  and  the  white  striae  were  well  marked. 
The  sacral  portion  of  the  cord  presented  no  abnormal  appearance  to 
the  naked  eye. 

Sections  of  the  cord  were  then  made  through  the  sclerosed  portions; 
and  it  was  seen  that  the  gray  matter  was  only  involved  where  the 
horns  approached  the  surface  ;  and  that,  wherever  a  lesion  existed, 
the  normal  contour  of  the  sections  was  altered  so  as  to  make  them  sub- 
ovoidal,  and  thus  to  lessen  the  circumference.  The  greatest  depth  of 
any  part  of  a  sclerosed  region  was  two-twelfths  of  an  inch,  and  this 
was  in  the  superior  patch.  The  average  thickness  was  about  the  one- 
twelfth  of  an  inch. 

The  whole  cord  in  my  possession  was  then  immersed  in  a  solution  of 
chromic  acid  in  water,  and  left  there  for  a  month  to  harden.  Immedi- 
ately previous  to  examining  with  the  microscope,  the  sections  were  col- 
ored by  an  ammoniacal  solution  of  carmine.  Under  a  twelfth-inch  ob- 
jective, it  was  seen  that,  throughout  the  whole  extent  of  the  sclerosed 
portion  of  any  section,  the  nerve-tubes  had  entirely  disappeared  ;  and, 
wherever  the  gray  substance  was  affected,  the  nerve-cells  were  dimin- 
ished in  number.  In  the  place  of  these  elements  were  connective  tis- 
sue, a  large  quantity  of  molecules,  and  connective-tissue  cells  in  great 
abundance. 

In  several  sections  taken  from  the  dorsal,  lumbar,  and  sacral  re- 
gions, and  which  were  apparently  normal  when  viewed  with  the  naked 
eye,  the  neuroglia  was  found  to  be  in  excess,  and  the  nerve-tubes  in  a 
state  of  disintegration. 

The  gray  matter,  except  in  those  sections  made  through  the  part 
where  the  sclerosed  portion  extended  from  the  white  matter  to  it,  was 
uniformly  healthy,  and  in  no  part  were  the  posterior  columns  in- 
volved. 

In  this  case  there  was  no  tremor,  although  it  was  clearly  one  of 
multiple  sclerosis,  probably  entirely  confined  to  the  spinal  cord.  At  no 
time  had  there  been  head-symptoms  of  any  kind.  Histologically, 
therefore,  we  see  that  the  sclerosed  tissue  consists  mainly  of  an  exces- 
sive amount  of  connective  tissue — the  neuroglia  of  Virchow.  The  cells 
are  increased  in  size,  and  the  nuclei  are  larger  and  much  more  numerous 


SECONDARY   INFLAMMATION   AND   DEGENERATION.  605 

than  in  the  normal  condition.     The  capillaries  are  thickened,  from  the 
deposition  on  their  walls  of  several  layers  of  rounded  cells. 

The  effect  of  this  morbid  process  is  to  compress  the  nervous  fila- 
ments and  to  cause  their  atrophy.  The  fluid  portion  undergoes  fatty 
degeneration,  and  the  axis  cylinders  become  disintegrated.  Still,  how- 
ever, they  present  somewhat  of  their  characteristic  color  and  consist- 
ency, and  appear  as  white  striae  traversing  the  morbid  tissue. 

The  membranes  often  exhibit  evidences  of  inflammation,  and  are 
thickened,  opaque  in  spots,  or  red  in  some  cases,  while  in  others  they 
are  adherent  to  each  other  and  to  the  cord. 

Treatment. — Something  can  be  done  to  mitigate  the  violence  of  the 
symptoms.  Hypodermic  injections  of  atropia  have  often  a  happy  effect 
in  diminishing  the  force  and  frequency  of  the  tonic  contractions.  The 
nitrate  of  silver  has  been  used  by  M.  Piorry  with  temporary  good  re- 
sults. 

The  primary  or  galvanic  current  has,  in  my  hands,  been  of  like  effi- 
cacy in  lessening  the  contractions  or  spasmodic  rigidity,  but  with  this 
agent,  as  well  as  with  the  others  mentioned,  there  can  be  no  great  cer- 
tainty that  we  are  dealing  with  a  case  of  multiple  spinal  sclerosis.  We 
are,  therefore,  forced  to  treat  symptoms  instead  of  lesions. 

Still,  for  the  cure  of  the  disease  we  may  attempt  the  measures 
recommended  for  symmetrical  lateral  sclerosis,  but  with  even  less 
prospect  of  success.  I  should  be  disposed  to  use,  with  thoroughness 
and  persistency,  the  actual  cautery  in  the  manner  recommended  when 
discussing  the  treatment  of  locomotor  ataxia. 

XI. 

SECONDARY   INFLAMMATION  AND   DEGENERATION   OF  THE    SPINAL   CORD. 

It  is  a  well-recognized  fact  that  disuse  of  an  organ  promotes  its 
atrophy  and  degeneration.  A  muscle,  which  from  any  cause  is  ren- 
dered incapable  of  contracting,  becomes  smaller,  and  its  fibrillse  under- 
go conversion  into  fat.  The  same  law  applies  to  other  organs,  and 
among  them  the  spinal  cord.  Whatever  interrupts  the  passage  of  the 
normal  excitations  through  its  columns  causes  degeneration.  Thus,  if 
there  he  a  cerebral  hemorrhage,  preventing  the  action  of  the  brain  on 
the  muscles,  the  lateral  pyramidal  trad  on  the  opposite  Bide  and  the 
anterior  pyramidal  tract  on  the  same  side  of  the  cord,  not  being  stim- 
ulated by  their  accustomed  excitation,  undergo  the  change  mentioned. 
If  the  cord  itself  be  the  seat  of  a  lesion,  or  the  posterior  nerve-roots, 
and    perhaps  even  the  nerves  or  muscles,  the   posterior  columns  above, 

no  longer  being  required  to  convey  impressions  to  the  brain,  Buffer 

atrophy   and   degeneration.      To   this  alteration,  which   is  not    itself  a 
primary  disease,  but  which   is  always,  in   its   very   nature,  consecutive 


606  DISEASES   OF   THE   SPINAL   CORD. 

to  lesions  in  superior  or  inferior  parts  of  the  nervous  system,  the  term 
secondary  degeneration  has  been  applied. 

The  fact  that  the  spinal  cord  is  affected  by  lesions  of  the 
brain  was  observed  by  Cruveilhier,1  who,  however,  failed  to  notice 
any  consecutive  change  in  the  cord  below  the  decussation  of  the 
pyramids. 

L.  Turck3  was  the  first  specially  to  inquire  into  this  important 
subject,  and,  in  a  series  of  memoirs  extending  through  the  years  from 
1851  to  1855,  he  showed  that  the  cord  underwent  secondary  degener- 
tion,  both  from  lesions  of  the  brain  and  of  its  own  substance.  Since 
these  memoirs,  other  pathologists,  among  whom  MM.  Charcot,  Turner, 
Rokitansky,  Vulpian,  Cornil,  and  Lancereaux,  may  be  mentioned,  re- 
ported cases,  but  no  one  has  investigated  the  subject  with  so  much 
thoroughness  as  M.  Bouchard.3 

Symptoms. — The  most  important  symptoms  referable  to  second- 
ary degeneration  of  the  cord  from  cerebral  lesions  are  muscular  con- 
tractions, exaggerated  tendon  reflexes,  and  the  ankle  clonus.  These 
are  not  the  contractions  which  sometimes  exist  from  the  very  in- 
ception of  a  haemorrhage,  for  instance,  but  those  which  come  on  at  a 
later  period  of  the  disease,  and  which,  like  the  first,  have  generally  been 
thought  the  consequence  of  irritation  existing  about  the  cicatrix.  Bou- 
chard, however,  shows  very  clearly  that  they  are  the  result  of  secondary 
changes  taking  place  in  the  spinal  cord,  and  the  clinical  history  of  which 
has  not  hitherto  been  carefully  studied.  They  are  very  frequent.  Of 
thirty-two  cases  of  old  hemiplegia  analyzed  by  Bouchard,  they  were 
present  in  all  but  one.  From  my  own  experience  I  think  it  is  safe  to 
say  that  it  is  very  rare  to  meet  with  a  case  of  hemiplegia  of  over  a 
year's  duration  in  which  they  do  not  exist. 

In  examining  a  patient  suffering  from  an  old  hemiplegia,  it  is  com- 
mon to  find  the  forearm  of  the  paralyzed  side  flexed  on  the  arm.  Fre- 
quently, also,  the  fingers  are  bent  into  the  palm  of  the  hand,  the  hand 
flexed  on  the  forearm,  and  the  whole  member  carried  across  the  front 
of  the  body,  and  held  firmly  against  it  by  the  contraction  of  the  pecto- 
ralis  major  muscle.  In  such  a  case  we  find  the  muscles  atrophied,  hard, 
and  stretched  to  an  extreme  degree  of  tension.  Rectification  of  the 
position  is,  to  a  great  extent,  impossible  by  the  voluntary  efforts  of  the 
patient.  lie  may  be  able  to  accomplish  a  little  motion,  and  to  do  still 
more  by  using  the  sound  hand  to  extend  the  affected  arm  ;  but,  if  the 
hemiplegia  has  been  of  considerable  duration,  the  range  of  his  motility, 
with  or  without  assistance,  is  very  small,  and  is  sometimes  nothing.     I 

1  "Anatomic  Pathologique,"  liv.  xxxii.,  p.  15. 

9  "  Ueber  secondare  Erkrankung  einzelner  Riiekenmarksstrangc  und  ihrer  Forsetzun- 
gen  zum  Gehirne,"  "  Sitzungsberichte  der  Kaiserlichen  Wiener  Academie,"  1851. 

•  "  Des  degenerations  secondares  de  la  moelle  6piniere,"  Archives  generates  dt 
mid.,  1806. 


SECONDARY   INFLAMMATION   AND   DEGENERATION. 


607 


have  found  that  the  electric  contractility  of  such  muscles  is  diminished 
in  some  of  their  fibres,  unaffected  in  others,  and  exalted  in  others,  so 
that,  when  the  electrical  stimulus  is  applied,  a  hard,,  irregular,  and 
knotty  contraction  is  obtained.  Polar  degenerative  reactions  are  not 
observed. 

The  leg  is  usually  stiff,  and  flexion  of  the  knee-joint  is  performed 
with  difficulty.  The  foot  is  generally  flexed  till  it  is  brought  into  a 
position  of  talipes  equinus.  This  gives  a  marked  peculiarity  to  the 
gait.  The  flexion  of  the  foot  prevents  the  toes  from  being  drawn 
upward  when  the  leg  is  thrown  forward,  as  in  the  act  of  walking. 
This,  in  addition  to  the  rigidity  of  the  knee-joint,  makes  it  necessary 
for  the  leg  to  be  thrown  outward  from  the  body  while  the  foot  de- 
scribes the  arc  of  a  circle. 

This  condition  of  contracture  only  affects  those  muscles  which 
have  previously  been  paralyzed. 

The  knee-jerk,  and  the  tendon  reflexes  generally,  are  exaggerated, 


Fig.  86. 


/JMC 


Diagrammatic  representation  of  the  connections  of  the  motor  nerve-cells  of  the  anterior 
horn,    i  Modified  from  Bmmvell.  | 

tpt,  Lateral  pyramidal  tract,  apt,  Anterior  pyramidal  tract,  or  oolnmn  of  Torek. 
pmc,  Posterior  median  column,  or  column  of  GolL  /"  ••,  Posterior  external  column, 
or  column  of  Bnrdaob.  dte,  Direct  cerebellar  tract,  a-l  m,  Antero-lateral  ascend- 
ing tract,  or  column  of  Sowers,  .1/.  a  muscle.  2,  adeep  reflex  fibre  passing  through 
the  posterior  external  column  and  joining  the  motor  nerve-cell  at  •''•.  >'.  superficial 
reflex  fibre  passing  through  the  posterior  horn  of  gray  matter  and  joining  the  motor 
cell  at  2.  l.  Fibre  connecting  the  lateral  pyramidal  tract  with  a  motor  cell.  i.  Motor 
nerve-fibre  from  motor  cell  to  muscle.  5,  Motor  nerve-flbre  from  the  anterior  pyram- 
idal tract  to  motor  nerve-oell. 

and  the  ankle  clonus  can  readily  be  obtained     In  fact,  the  Bymptomfl 
are  nearly  identical  with  those  described  under  the  heading  of  Pri- 


608  DISEASES  OF  THE   SPINAL   CORD. 

mary  Sclerosis  of  the  Lateral  Pyramidal  Tracts,  on  page  549,  with 
the  exception  that  in  that  disease,  where  the  lesion  begins  primarily 
in  the  spinal  Qord,  both  legs  are  affected,  while  in  the  disease  under 
consideration  the  degeneration  of  the  motor  tract  is  mainly  limited  to 
the  entire  lateral  pyramidal  tract  of  one  side,  so  that  the  symptoms 
are  manifested  in  the  arm  and  leg  of  that  side  only.  As  a  cerebral 
haemorrhage  usually  takes  place  in  the  motor  tract  above  the  decussa- 
tion in  the  pons,  the  descending  degeneration  Mill  not  be  entirely 
limited  to  the  lateral  pyramidal  tract.  A  portion  of  the  cerebral 
motor  fibres  do  not  decussate,  but  continue  downward  in  the  same 
side  of  the  cord  in  what  is  known  as  the  columns  of  Tiirck,  or  the 
anterior  pyramidal  tract  (Fig.  70,  page  554). 

This  column  probably  connects  with  the  cells  in  the  anterior  horn 
of  gray  matter  of  the  same  side.  Usually  the  anterior  pyramidal 
tract  contains  but  a  small  proportion  of  the  cerebral  motor  fibres, 
hence  the  three  cardinal  symptoms  of  inflammation  of  the  spinal 
motor  tract — that  is,  stiffness,  exaggerated  tendon  reflexes,  and  the 
ankle  clonus — will  be  very  slightly  defined  on  what  is  usually  termed 
the  sound  side.  Most  frequently  stiffness  is  not  appreciated  on  that 
side  at  all,  the  knee-jerk  is  found  to  be  slightly  exaggerated,  and 
there  may  be  a  tendency  to  the  ankle  clonus,  which,  however,  is  sel- 
dom well  marked. 

Atrophy  of  the  paralyzed  muscles  may  be  one  of  the  secondary 
results  of  brain-disease  ;  as  we  have  seen,  it  is  of  a  primary  spinal 
affection. 

When  the  coi'd  itself  is  the  seat  of  primary  disease,  the  lateral  col- 
umns below  undergo  degeneration,  and  the  muscles  become  perma- 
nently contracted.  Many  cases  of  distortion  which  ensue  on  sclerosis, 
tumors,  and  other  lesions,  are  the  result  of  this  secondary  degenera- 
tion. M.  Charcot  is  of  the  opinion  that  the  epileptiform  attacks 
sometimes  met  with  in  hemiplegics  may  result  from  these  secondary 
descending  degenerations  affecting  the  peduncles,  the  pons,  and  the 
medulla  oblongata. 

No  symptoms  referable  to  ascending  secondary  degenerations — 
those  of  the  posterior  columns — have  been  recognized  except  in  a  few 
instances,  and  then  the  symptoms  differ  but  little  from  those  previ- 
ously described  under  the  heading  of  Locomotor  Ataxia. 

Causes. — Secondary  descending  degeneration  of  the  spinal  cord 
may  result  from  primary  lesions  of  the  cerebral  motor  cortex,  of  the 
motor  fibres  of  the  internal  capsule,  of  the  pons  Varolii,  of  the  me- 
dulla oblongata,  and  of  the  spinal  cord  itself.  Secondary  ascending 
degeneration  of  the  posterior  columns  is  caused  by  disease  of  the 
posterior  roots  of  the  spinal  nerves,  and  from  lesions  originating  in 
some  other  part  of  the  cord  gradually  extending  in  area  until  the  pos- 
terior columns  become  involved.     The  immediate  causes  are  the  loss 


SECONDARY   INFLAMMATION   AND   DEGENERATION.  609 

of  the  due  supply  of  arterial  blood,  and  the  arrest  of  nutritive  action 
from  deficient  nervous  influence. 

The  Diagnosis  calls  for  no  special  consideration. 

Prognosis. — This  is  very  unfavorable.  Cerebral  motor  nerve-fibres 
whose  continuity  is  interrupted  by  any  lesion  which  separates  them 
from  the  cortical  nerve-cells  which  supply  them  with  their  nutrition, 
invariably  degenerate.  This  degeneration  consists  of  an  inflamma- 
tory destruction  of  the  nerve-fibres,  with  a  consequent  proliferation 
of  new  connective  tissue,  and  is  termed  sclerosis.  Unless  it  is  pos- 
sible to  restore  the  destroyed  nerve-fibres,  and  to  resolve  the  hard- 
ened and  increased  quantity  of  connective  tissue  to  its  normal  con- 
dition— which  it  is  very  evident  we  cannot  do — it  can  be  seen  at  a 
glance  how  utterly  hopeless  is  the  prospect  of  even  an  amelioration 
of  the  symptoms. 

Morbid  Anatomy  and  Pathology. — Secondary  degeneration  is  gen- 
erally found  in  the  white  substance,  the  gray  being  seldom  affected. 
This  might  certainly  have  been  expected,  owing  to  the  fact  that  it  is 
the  conducting  power  of  the  cord  only  that  is  lessened,  and,  as  this 
power  resides  almost  entirely  in  the  fasciculi  of  the  white  substance 
in  the  lateral  pyramidal  tract  and  posterior  columns,  it  is  here  that  we 
ordinarily  find  the  lesions.  When  a  fibre  belonging  to  the  white  sub- 
stance is  injured,  either  in  the  cord  or  in  its  intra-cranial  prolonga- 
tions, the  secondary  degeneration  ensues  either  above  or  below  the 
seat  of  the  primary  lesion,  but  it  extends  through  the  entire  length  of 
this  portion  to  its  central  or  peripheral  extremity,  according  as  it  in- 
volves sensory  or  motor  filaments.  To  these  two  varieties  the  terms 
ascending  and  descending  degeneration  are  applied.  The  affected 
fibres  alone  an;  changed,  and  the  alteration  extends  throughout  their 
whole  length.  But.  as  the  white  fibres  are  constantly  receiving  other 
fibres  which  have  had  no  initial  injury,  the  secondary  degeneration 
becomes  relatively  less  the  greater  the  distance  is  from  the  seat  of  the 
primary  lesion. 

The  morbid  condition  depends  upon  three  processes :  atheroma  of 
the  capillaries  and  the  formation  of  granular  corpuscles  in  the  degen- 
erated tissue  ;  the  degeneration  and  atrophy  of  a  greater  or  less  num- 
ber of  nervous  fllament8;  the  proliferation  of  connective  tissue  which 
takes  the  place  of  the  nerve-tube8.  These  changes  are  similar  to  those 
which  occur  in    the   several  forms  of  sclerosis,  to  which   attention   has 

already  been  directed,  and  are  essentially  inflammatory  in  character. 

The   explanation   of   the    rigidity   of    the    muscles,   the    presence   of 

contractures,  of  exaggerated  tendon-reflexes,  and  of  the  ankle  clo- 
nus, is   identical  with  that  which   has   been   given    for  this  same  group 

of  symptoms  described  under  the  heading  of  Morbid  Anatomy  and 
Pathology,  in  the  chapter  on  Primary  Sclerosis  of  the  Lateral  Pyram- 
idal Tract. 

40 


610  DISEASES   OF   THE   SPINAL   CORD. 

When  there  is  atrophy  of  the  paralyzed  and  contracted  muscles  as 
a  result  of  secondary  degeneration  of  the  cord,  we  may  be  very  sure 
that  the  anterior  horns  of  gray  matter  are  involved.  Charcot '  cites  a 
case  which  he  reported  to  the  Societe  de  Biologie,  in  which  a  woman 
aged  seventy  was  suddenly  struck  with  left  hemiplegia,  occasioned,  as 
the  post-mortem  examination  showed,  by  a  cerebral  haemorrhage  seat- 
ed in  the  centrum  ovale  of  the  right  hemisphere.  Contraction  of  the 
paralyzed  muscles  supervened  very  soon,  and,  two  months  after  the 
attack,  the  muscles  of  the  inferior  as  well  as  of  the  superior  extrem- 
ity began  to  atrophy  at  the  same  time  that  their  electric  contractil- 
ity was  notably  diminished.  The  muscular  atrophy  advanced  with 
great  rapidity,  and  simultaneously  the  skin  on  the  paralyzed  parts, 
when  submitted  to  pressure,  was  the  seat  of  numerous  bullae  and  even 
erosions. 

The  examination  of  the  spinal  cord  revealed  the  existence  of  a 
descending  sclerosis,  occupying  the  left  side,  and  presenting  its  ordi- 
nary features.  But  in  addition,  at  several  points  of  the  cervical 
and  lumbar  enlargements,  the  anterior  horn  of  gray  matter  of  the 
same  side  exhibited  evidences  of  an  inflammatory  process,  and  at 
these  points  the  large  nerve-cells  had  undergone  a  mai'ked  degree  of 
atrophy. 

Similar  cases  have  been  reported  by  Hallopeau. 

Treatment. — The  best  results  in  my  experience  have  been  obtained 
from  the  use  of  the  primary  galvanic  current  to  the  cord,  the  same  or 
the  induced  current  to  the  muscles,  forcible  extension  and  flexion  of 
the  contracted  limbs,  and  the  internal  administration  of  nitrate  of  sil- 
ver and  cod-liver  oil.  It  will  generally  be  found  that  the  opposing 
muscles  are  more  or  less  paralyzed,  and  that  great  good  may  be  effect- 
ed by  stimulating  them  with  the  primary  or  induced  currents.  The 
division  of  tendons  is  never  necessary,  unless  for  the  rectification  of 
distortions  of  the  toes  or  fingers.  Sometimes  the  toes  are  strongly 
flexed  against  the  sole  of  the  foot,  rendering  it  almost  impossible  to 
walk,  from  the  pain  produced  by  the  dorsal  surface  being  brought  in 
contact  with  the  ground,  and  hence  obliged  to  bear  the  weight  of  the 
body.  In  such  cases  the  tendons  may  wTith  propriety  be  divided,  un- 
less the  toes  can  be  kept  extended  by  some  convenient  prothetic  appa- 
ratus, or,  as  in  the  case  under  my  care,  to  which  reference  has  been 
made,  the  toe  may,  if  necessary,  be  amputated. — Passive  exercise  of 
the  affected  muscles  will  do  much  to  restore  them. 

1  "  Lecjons  sur  les  maladies  du  systemc  nerveux,"  1874,  p.  245. 


NON-INFLAMMATORY   SOFTENING   OF   THE   SPINAL   CORD.  611 

CHAPTER  VI. 

NON-INFLAMMATORY  SOFTENING    OF  THE  SPINAL    CORD. 

Softening  of  the  spinal  cord  is,  as  we  have  seen,  the  common 
termination  of  acute  myelitis,  in  which  connection  it  has  been  suf- 
ficiently considered  ;  but  it  may  originate  primarily,  and  in  that 
event  possesses  a  clinical  history  very  distinct  from  that  of  acute 
inflammatory  softening. 

Symptoms. — The  first  symptom  usually  noticed  in  softening  of  the 
spinal  cord  is  numbness  in  those  parts  of  the  body  below  the  seat  of  the 
lesion.  Soon  after  the  occurrence  of  this  symptom  there  is  weakness  of 
the  same  parts,  and  then  the  deficiency  of  sensation  and  the  feebleness 
of  motor  power  advance  together,  both  gradually  becoming  more  and 
more  strongly  marked.  There  are  no  muscular  twitchings,  no  contrac- 
tions of  the  limbs,  no  pains  either  at  the  seat  of  the  disease  or  in  the 
paralyzed  limbs. 

The  bladder  very  soon  becomes  involved,  and  the  patient  finds  that, 
when  he  attempts  to  urinate,  the  stream  is  not  so  strong  as  it  once  was, 
and  that  he  is  obliged  at  times  to  use  the  expulsive  force  of  the  abdomi- 
nal muscles  in  order  to  complete  the  evacuation  of  the  bladder.  Gradu- 
ally the  contractile  power  of  this  viscus  becomes  less,  and  finally  is 
altogether  lost. 

The  sphincter  generally  participates.  The  desire  to  urinate  becomes 
more  frequent,  and  when  the  inclination  is  felt  the  patient  must  at  once 
yield  to  it.  Eventually  the  bladder  likewise  becomes  entirely  paralyzed, 
and  then  there  is  neither  the  ability  to  expel  the  urine  nor  to  retain  it, 
and  consequently  it  dribbles  away  constantly. 

Sometimes  the  first  evidence  of  softening  of  the  cord  is  perceived 
either  in  the  bladder  or  its  sphincter,  and  it  may  be  restricted  to  these 
parts  for  a  considerable  period.  I  have  a  patient  at  the  present  time 
under  treatment  for  what  I  have  no  doubt  is  softening  of  the  cord,  and 
in  whom  the  bladder-troubles  were  the  only  notable  symptoms  for  over 
two  years. 

The  intestines  are  similarly  affected,  and  the  bowels  are  either  ob- 
stinately constipated  or  the  sphincter  ani  is  relaxed,  leading  to  fecal 
evacuations  as  soon  as  the  contents  reach  the  rectum. 

Reflex  excitability  is  weakened  from  the  first,  and  gradually 
disappears,  unless,  as  is  rarely  the  case,  the  gray  matter  be  un- 
affected. 

The  progressive  advance  of  the  disease  reduces  the  patient  to  a 

condition  of  utter  helplessness.       lie   is   unable   to    walk,   sensation    is 

abolished  in  the  paralyzed  limbs,  his  mine  and  faces  are  passed  in- 


61 2  DISEASES   OF   THE   SPINAL   CORD. 

voluntarily,  bed-sores  occur,  the  venereal  appetite  is  extinct,  or,  if 
it  should  remain,  erections  are  impossible,  and  the  parts  of  the  body 
below  the  seat  of  the  disease  are  to  all  intents  and  purposes  cut  off 
from  communication  with  the  parts  above.  This  condition  may  last 
for  years  without  a  fatal  termination  ensuing,  but  intercurrent  affec- 
tions, especially  resulting  from  the  bladder  troubles,  may  eventually 
cause  death. 

Such  is  the  course  of  spinal  softening  when  the  lesion  is  low  down 
and  involves  both  antero-lateral  and  posterior  columns.  When  it  is 
higher  up,  the  symptoms  are  also  referable  to  the  thoracic  extremities, 
and  to  the  muscles  concerned  in  deglutition  and  respiration.  There 
are  likewise  visceral  disturbances. 

When  the  lesion  mainly  affects  or  is  confined  to  the  lateral  pyram- 
idal tract,  the  symptoms  manifested  are  in  intimate  relation  with  the 
known  physiological  functions  of  the  region  in  question.  Thus  the 
power  of  motion  in  the  limbs  below  the  softened  portion  of  the  cord 
gradually  becomes  less,  the  gait  is  from  the  first  staggering,  and,  though 
even  at  a  late  stage  the  patient  may  be  able  to  move  his  limbs  while 
lying  down  or  sitting,  he  cannot  support  the  weight  of  his  body  upon 
them.  When  he  tries  to  stand  without  extraneous  aid,  it  is  seen  that 
he  is  especially  weak  in  the  knees  and  ankles.  There  is  no  more  diffi- 
culty in  standing  or  walking  with  the  eyes  shut  than  when  they  are 
open. 

This  paralysis  of  motion,  in  which  the  bladder  generally  participates, 
may  be  of  the  most  profound  degree,  and  yet  sensibility  be  perfect. 
A  gentleman  was  under  my  care  in  whom  I  diagnosticated  softening  of 
the  cord  in  that  part  extending  on  the  right  side  from  the  second  dorsal 
vertebra  downward  probably  as  far  as  the  fourth  sacral,  while  on  the 
left  side  it  began  at  about  the  fourth  lumbar  and  extended  downward 
probably  as  low  as  the  fourth  sacral.  I  gave  the  lesion  these  topo- 
graphical limits  for  the  reason  that  on  the  right  side  the  muscles  sup- 
plied by  the  crural  and  sciatic  nerves  had  lost  their  electro-muscular 
contractility,  while  it  certainly  did  not  extend  above  the  origin  of  the 
ilio-hypogastric  nerve,  as  the  lower  part  of  the  rectus  abdominis,  which 
receives  its  motor  power  through  this  nerve,  retained  its  contractile 
power.  On  the  left  side  the  muscles  supplied  by  the  crural  nerve  were 
possessed  of  their  normal  motor  power,  while  those  supplied  by  the 
sciatic  had  lost  their  contractility.  It  was,  therefore,  very  certain  that 
on  this  side  the  lesion  did  not  extend  above  the  fourth  lumbar,  the 
lowest  spinal  nerve  contributing  to  the  formation  of  the  crural. 

I  was  able  also  to  restrict  the  morbid  process  entirely  to  the  antero- 
lateral columns,  for  in  no  part  of  the  skin  below  the  upper  supposed 
limit  of  the  lesion  was  there  any  loss  of  sensibility.  The  least  impres- 
sion made  upon  the  skin  was  felt.  Tickling  the  sole  of  the  foot  excited 
laughter,  but  no  reflex  movements.     I  was  therefore  able  to  determine 


NON-INFLAMMATORY    SOFTENING   OF   THE   SFLNAL  CORD.  613 

that  the  gray  matter  was  involved.  The  bladder  was  paralyzed,  and 
its  sphincter  likewise.  The  sphincter  ani  was  also  deprived  of  its  con- 
tractile power  to  a  great  extent. 

The  patient  died  at  Cape  May,  and  I  had  no  opportunity  of  making 
a  post-mortem  examination.  Probably,  however,  the  lesion  was  essen- 
tially that  which  I  have  described.  In  all  cases  of  spinal  softening  in- 
volving the  antero-lateral  columns,  the  electro-muscular  contractility  is 
soon  lost,  so  that  even  the  strongest  induced  or  primary  currents  fail 
to  cause  contractions. 

As  regards  the  implication  of  the  posterior  columns,  there  is  an 
equal  facility  for  determining  the  fact  from  a  consideration  of  the  symp- 
toms. The  functions  of  these  columns  are  intimately  connected  with 
sensation,  and  when  such  a  morbid  process  as  softening  is  set  up  in 
them  the  symptoms  are  those  which  indicate  impairment  of  the  cutane- 
ous and  muscular  sensibility.  Thus,  in  a  gentleman  formerly  under  my 
charge,  there  had  been  going  on  for  several  months  a  morbid  action  in 
the  spinal  cord  unattended  by  any  prominent  symptoms  except  anaes- 
thesia. There  had  never  been  pain  or  any  derangement  of  motility, 
but  simply  a  gradually-increasing  loss  of  sensibility  in  both  lower  ex- 
tremities and  in  all  the  other  parts  of  the  body  below  the  upper  limit 
of  the  seat  of  the  lesion. 

He  was  unable  to  walk  in  the  dark  or  with  his  eyes  shut,  or  to  stand 
alone  with  his  eyes  closed  and  his  feet  close  together,  for  he  obtained 
no  idea  of  his  position  unless  he  could  have  the  aid  of  his  eyes  or  hands. 

He  had  full  power  over  the  bladder  and  voluntary  control  over  its 
sphincter  and  that  of  the  rectum,  but  he  never  experienced  the  desire 
to  urinate,  did  not  feel  the  flow  of  urine  through  the  urethra,  nor  the 
passage  of  the  fasces  through  the  anus,  and  evacuated  his  bladder  and 
bowels  at  stated  periods  merely  from  the  knowledge  acquired  by  ex- 
perience that  it  was  time  to  do  so. 

Examination  with  the  jcsthesiometer  showed  that  the  upper  limit  of 
the  lesion  on  both  sides  was  in  that  part  of  the  cord  from  which  the 
second  lumbar  nerves  are  derived,  for  the  loss  of  sensibility  was  appar- 
ent in  all  those  parts  supplied  by  the  crural  and  sciatic  nerves,  both  as 
regarded  the  skin  and  the  muscles.  Very  weak  faradaic  currents  caused 
muscular  contractions,  but  the  strongest  which  it  was  possible  to  ob- 
tain from  a  powerful  machine  produced  no  pain. 

There  was  no  muscular  incoordination,  neither  had  there  ever  been 
electric-like  pains  in  any  part  of  the  body.  The  patient  died  in  1873. 
For  a  year  previously  he  had  exhibited  indications  of  insanity,  and 
finally  committed  suicide  by  hanging  himself  to  his  bedpost.  A  post- 
mortem examination  was  made  of  his  brain,  but  the  physician  ivho  then 
had  charge  of  the  case  thought  it  too  great  a  trouble  to  examine  the 
cord,  and  thus  an  opportunity  for  studying  what  must  necessarily  bav« 
been  important  lesions  was  lost. 


614  DISEASES   OF  THE   SPINAL   CORD. 

In  this  case  there  was,  I  think,  ample  reason  to  diagnosticate  a 
lesion  of  the  posterior  columns  without  any  implication  of  the  antero- 
lateral. The  reasons  for  believing  this  lesion  to  have  been  softening 
will  be  indicated  under  the  head  of  diagnosis. 

Causes. — The  causes  of  spinal  softening  are  not  very  clearly  under- 
stood. Doubtless  it  arises  as  a  consequence  of  acute  myelitis,  but  it  is 
often  an  independent  and  apparently  a  primary  affection,  being  unpre- 
ceded  by  any  obvious  symptoms  indicative  of  spinal  derangement. 
Such  influences  as  give  rise  to  cerebral  softening  will,  in  all  probability, 
cause  spinal  softening,  and  among  them  must  be  placed  obliteration  of 
blood-vessels  from  embolism  and  thrombosis.  The  actual  occurrence  of 
occlusion  of  spinal  vessels  from  either  of  these  causes  has  not,  however, 
so  far  as  I  am  aware,  been  demonstrated.  The  further  etiology  of  spi- 
nal softening  is  not  as  yet  a  matter  of  any  certainty,  though  I  think 
several  cases  that  have  been  under  my  observation  could  reasonably 
have  their  cause  laid  to  excessive  sexual  indulgence. 

Diagnosis. — The  diagnostic  marks  of  most  value  in  cases  of  sup- 
posed spinal  softening  are  the  absence  of  sensory  and  motor  excite- 
ment. Thus  there  are  no  pains  referable  to  the  back  or  other  parts  of 
the  body,  no  hyperesthesia,  no  twitchings,  no  spasms,  no  contractions, 
no  exalted  reflex  actions.  And  this  is  the  case  in  that  form  of  the  dis- 
ease involving  the  whole  thickness  of  the  cord,  or  in  either  of  those 
limited  to  the  anterior  or  posterior  columns.  There  is  no  other  affec- 
tion of  the  spinal  cord  which  is  not  characterized,  at  some  time  or  other 
of  its  progress,  by  irritation  either  of  the  sensory  or  motor  nerves,  or 
of  both,  excepting  some  cases  of  spinal  anaemia  giving  rise  to  the  cate- 
gories of  symptoms  previously  considered.  The  clinical  history  of  such 
cases,  and  the  comparatively  light  character  of  the  phenomena,  will 
serve  to  distinguish  them  from  those  in  which  the  lesion  is  softening. 

Prognosis. — The  prognosis  is  always  unfavorable  as  regards  recov- 
ery and  complete  restoration,  but  spinal  softening  is  not  necessarily 
a  fatal  disease.  At  least,  I  have  seen  cases  which  had  existed  for  many 
years,  and  which  apparently  had  no  elements  of  a  fatal  termination 
about  them.  But  they  were  instances  in  which  the  seat  of  the  disease 
was  in  the  lower  dorsal,  or  lumbar  or  sacral  region  of  the  cord.  When 
it  is  higher  up,  the  prospect  of  death  ensuing  is  more  probable.  The 
restoration  of  the  cord  to  its  normal  structure  is  impossible,  and  the 
patient  lies  paralyzed  either  in  sensation  or  motion,  or  both,  according 
to  the  situation  and  extent  of  the  lesion,  in  a  condition  similar  to  that 
of  a  person  who  has  received  a  wound  inflicting  irreparable  injury  on 
the  cord.  Such  persons,  as  is  well  known,  frequently  live  for  many 
years  afterward — then  die  of  some  entirely  different  disease.  There  is 
nothing  about  spinal  softening  calculated  to  produce  exhaustion,  un- 
less it  be  the  tendency  which  exists  to  cystitis  from  paralysis  of  the 
bladder,  and  the  consequent  inflammation  liable  to  be  set  up  from  the 


NON-INFLAMMATORY   SOFTENING   OF   THE   SPINAL   CORD.  615 

action  of  the  retained  urine.  Care,  however,  will  very  greatly  diminish 
the  danger  from  this  source.  I  have  had  a  number  of  patients  under 
my  charge  who  had  not,  for  many  years,  had  a  passage  of  urine  from 
the  bladder  which  was  not  effected  with  the  catheter,  and  they  had,  in 
all  that  time,  suffered  no  marked  inconvenience. 

Morbid  Anatomy  and  Pathology. — The  appearance  of  a  softened 
portion  of  the  spinal  cord  to  the  naked  eye  has  nothing  very  peculiar 
about  it.  When  examined  as  to  its  consistence,  it  is  seen  to  be  some- 
times as  soft  as  cream,  at  others  scarcely  altered  in  the  resistance  which 
it  offers  to  the  touch.  In  the  first  instance,  when  the  lesion  involves 
the  gray  and  white  matter  together,  section  does  not  show  the  peculiar 
double  crescentic  arrangement  of  the  former  tissue,  but  it  appears  to  be 
blended  homogeneously  with  the  white  substance  which  surrounds  it. 

Microscopically  it  is  seen  that  the  nervous  tubules  constituting  the 
essential  anatomical  elements  of  the  white  substance  are  broken  up, 
and  no  vestige  of  them  remains  in  extreme  cases — oil-globules  and 
bodies  called  granule-masses,  the  constituent  of  which  is  fat,  having 
taken  their  place.  In  the  gray  substance  the  nervous  cells  are  de- 
stroyed, and  oil  and  fat  have  made  their  appearance  in  large  amount. 
Even  the  neuroglia  or  connective  tissue  of  the  cord  exhibits  a  similar 
disintegration  and  regressive  metamorphosis.  These  changes  impair 
the  functions  of  the  cord,  both  as  a  nervous  centre  and  as  a  structure 
serving  for  the  transmission  of  sensory  impressions  to  the  brain,  and  of 
nervous  force  from  it.  When  the  disintegration  is  complete,  the  effect 
is  the  same  as  if  the  cord  had  been  entirely  divided  by  a  cutting  in- 
strument. 

Treatment. — There  is  nothing  to  be  done  which  can  by  any  possi- 
bility restore  the  integrity  of  the  spinal  cord  after  the  process  of  soft- 
ening has  fairly  entered  upon  its  course.  In  the  very  early  stages,  if 
patients  apply  for  treatment  at  these  times,  something  may  perhaps  be 
accomplished  by  the  use  of  phosphorus  and  strychnia,  but  the  symp- 
toms come  on  so  insidiously  and  gradually  that  the  subject  of  them 
rarely  has  his  apprehensions  excited  till  it  is  too  late  to  do  any  thing 
toward  arresting  the  disease.  And  even  when  we  do  see  cases  which 
in  appearance  exhibit  the  symptoms  met  with  in  spinal  softening  in  its 
initial  stage,  and  which  recover  under  treatment,  there  must  always  be 
a  doubt  in  regard  to  the  accuracy  of  the  diagnosis — for  many  cases  of 
temporary  anaesthesia  and  impairment  of  motility  are  due  to  anemia  of 
the  cord,  the  result  of  the  causes  set  forth  in  a  previous  ohapter. 

The  patient,  however,  may  be  made  comfortable  to  such  an  extent 
as  to  materially  prolong  his  life.  Care  should  to  this  end  be  taken 
that  he  lines  not.  sustain  a  fall  or  suffer  an  injury  whereby  the  diffluenl 
portion  of  the  cord  would  be  disturbed  in  its  anatomical  relations,  and 
the  danger  of  an  attack  of  acute  meningitis  or  of  myelitis  incurred. 
Bed-SOres  should  be  prevented,  or,  if  they  occur,  treated  according  to 


616  DISEASES   OF  THE   SPINAL   CORD. 

the  methods  previously  mentioned,  and  full  instructions  should  be 
given  in  regard  to  emptying  the  bladder  with  the  catheter  at  regular 
times,  and  of  going  to  stool  at  the  same  hour  every  day.  Locomotion 
may  be  provided  for  by  some  one  of  the  chairs  devised  for  the  use  of 
paraplegics.  As  there  is  little,  in  softening  of  the  cord  situated  below 
the  origin  of  the  phrenic  nerves,  which  is  directly  calculated  to  de- 
stroy life,  there  is  no  reason  why,  with  the  adoption  of  proper  meas- 
ures, the  patient  should  not  enjoy  a  measurable  degree  of  comfort  for 
many  years.  Probably  the  event  most  apt  to  occur  is  acute  or  chronic 
cystitis  from  paralysis  of  the  bladder,  but  attention  to  the  injunction 
above  given  will  do  much  toward  lessening  the  liability  to  this  affec- 
tion. 


CHAPTER  VII. 

TUMORS   OF  THE  SPINAL  CORD. 

Following  the  example  of  Jaccoud,  I  shall  consider  under  one  head, 
tumors  of  the  cord,  of  the  membranes,  and  those  which,  growing  from 
the  interior  surfaces  of  the  vertebrae,  may  compress  the  cord,  and  thus 
interfere  with  its  functions  by  deranging  its  structure.  In  the  present 
state  of  our  knowledge,  we  have  not  many  exact  data  by  which  to  dis- 
criminate between  these  several  growths. 

Symptoms. — The  phenomena  which  result  from  intra-spinal  tumors, 
like  those  due  to  congestion,  are  of  two  categories,  resulting  as  they  do 
either  from  irritation  or  compression.  Under  the  first  head  are  em- 
braced pain  in  the  back,  in  the  limbs,  and  in  the  viscera,  if  the  poste- 
rior columns  are  mainly  the  seat  of  the  lesion  or  subjected  to  the  press- 
ure of  a  vertebral  tumor,  and  twitchings  of  the  muscles,  and  contrac- 
tions of  the  limbs,  if  the  antero-lateral  columns  are  principally  involved. 
When  both  sets  of  columns — as  is  generally  the  case — are  affected,  the 
troubles  of  sensibility  and  of  motility  are  both  present. 

If  the  tumor  is  situated  in  the  cervical  or  upper  dorsal  region,  there 
is  generally  tonic  contraction  of  the  muscles  of  the  neck  by  which  the 
head  is  thrown  backward,  causing  the  patient  to  present  the  appear- 
ance of  a  person  affected  with  the  opisthotonos  of  tetanus.  There  are 
in  such  a  case  usually  ocular  troubles,  such  as  those  previously  men- 
tioned, and  more  or  less  gastric  derangement.  The  symptoms,  so  far 
as  the  limbs  and  viscera  are  concerned,  vary  in  their  extent  according 
to  the  situation  of  the  morbid  growth. 

The  symptoms  of  strong  compression  are  anaesthesia  and  motor  pa- 
ralysis. These  may  or  may  not  be  accompanied  with  muscular  atrophy. 
Reflex  excitability  and  electro-muscular  contractility  are  generally  at 
first  increased,  or  at  least  not  lessened,  but,  as  the  pressure  augments 


TUMORS   OF  THE  SPIXAL  CORD.  61 7 

and  the  structure  of  the  cord  becomes  more  disorganized,  they  are  less- 
ened. 

The  bladder  generally  retains  its  power,  but  if  the  tumor  be  situated 
so  as  to  compress  the  middle  of  the  dorsal  region  there  will  be  more  or 
less  difficulty  in  passing  the  urine  which  is  retained  through  spasm  of 
the  sphincter.  If  the  lesion  exists  at  the  upper  part  of  the  lumbar  re- 
gion, or  at  about  that  part,  the  bladder  and  sphincter  will  be  paralyzed, 
and  the  urine  will  dribble  continuously.1 

Many  cases,  of  what  may  with  Drs.  Charcot  and  Brown-Sequard  be 
called  hemi-paraplegia,  are  due  to  spinal  tumors.  It  often  happens 
that  these  are  small  and  compress  a  lateral  half  of  the  cord,  leaving  the 
other  affected  only  by  the  transmitted  pressure.  A  very  remarkable 
case  has  been  reported  by  Charcot,"  in  which  the  left  inferior  extremitv 
was  completely  paralyzed,  while  the  right  was  simply  weak  without 
having  lost  the  power  of  contraction  in  any  of  its  muscles.  On  the 
other  hand,  sensibility  was  greatly  lessened  in  the  right  limb,  while  it 
was  exalted  in  the  left.  There  was  paralysis  of  the  bladder,  but  no  at- 
rophy of  either  limb.  Finally,  anasarca  and  bed-sores  appeared,  and 
the  patient  gradually  sank.  On  post-mortem  examination,  a  tumor 
was  found  growing  from  the  dura  mater  on  the  anterior  face  of  the 
cord  and  compressing  its  left  lateral  half.  The  accompanying  wood- 
cuts (Figs.  87  and  88),  reduced  from  Charcot's  lithographic  repre- 
sentations, show  the  situation  and  relations  of  this  tumor.  Fig.  8? 
shows  the  growth  in  sitv,  and  Fig.  88  the  parts  as  they  appeared 
when  the  tumor  was  pushed  aside  so  as  to  allow  the  cavity  to  be  seen 
in  which  it  was  lodged.3 

Recollecting  the  facts  that  the  fibres  of  the  anterior  or  motor  col- 
umns of  the  cord  decussate  at  the  medulla  oblongata,  while  those  oi 
the  posterior  or  sensory  columns  cross  over  soon  after  they  enter  the 
cord  from  the  posterior  roots  of  the  spinal  nerves,  we  can  understand 
why,  when  the  paralysis  of  motion  is  confined  to  one  side,  or  is  greater 
on  that  side,  the  lesion  is  on  the  corresponding  side  of  the  cord, 
and  this  loss  of  motility  should  be  accompanied  with  anaesthesia  of  the 
opposite  side  of  the  body. 

Under  the  name  of  painful  paraplegia  (parapl&tjie  douloun  ust  ). 
Oruveilhier  referred  to  a  form  of  spinal  disease  which  has  been  subse- 
quently described  more  fully  by  Charcot.  This  latter  author  has  OD- 
d  six  cases,  in  all  of  which  there  was  cancer  of  the  mammary  gland, 
[n  three  of  these  he  had  the  opportunity  of  making  post-mortem  ex- 

1  Charcot,  "  Leoonf  box  lea  maladies  dn  Byst&me  nerveux  ;  Beconde  fascicule.  De  la  oonv 
m  lente  '!<•  la  moelle  epiniere,"  Paris,  1878,  p.  114. 

1  Archive$  de  phyaioloffie,  No.  2,  p.  'J'Jl. 

•  This  ense  is  quoted  al  length  by  I>r.  Brown-Sequard  in  the  Lancet  of  September  25, 
L869,  p.  420.  In  previous  and  subsequent  cumbers  of  this  journal  Brown-Sequard  bus 
sontributed  much  valuable  Information  on  the  subject  of  hemi-paraplegia. 


018 


DISEASES   OF   THE   SPINAL   CORD. 


animations,  and  discovered  carcinoma  of  a  lumbar  vertebra  in  each,  to 
which  the  irritation  and  compression  of  the  cord  were  due.  According 
to  him,  "  the  skin,  especially  during  the  paroxysms  of  pain,  is  often 


Fig.  87. 


Fig.  88. 


// 


■/a 


M: 


very  sensitive  to  the  touch.  At  the  same  time  walking  becomes  trouble- 
some, and  later  the  patient  cannot  walk  without  help;  finally,  muscular 
atrophy  ensues,  and  the  patient  loses  the  power  to  stand." 

Simon,  from  whom  I  quote  these  details,  under  the  head  of  "  para- 
plegia  dolorosa,"  describes  a  case  which  came  under  his  own  observa- 
tion, in  which,  during  life,  symptoms  similar  to  those  mentioned  by 
Charcot  were  noticed,  and  in  which,  after  death,  a  cancerous  tumor 
was  found  growing  from  the  first  lumbar  vertebra  and  compressing  the 
posterior  columns  of  the  cord.  Other  lesions  were  present  in  the  pos- 
terior columns  both  above  and  below  the  tumor  ;  they  were  appar- 
ently of  the  nature  of  sclerosis.  Similar  cases  have  been  described  by 
other  authors. 

Although  it  is  rendered  certain  that  cancerous  tumors  of  the  verte- 
brae may  give  rise  to  paraplegia  characterized  by  great  pain,  it  must  be 
borne  in  mind  that  these  symptoms  are  not  a  necessary  accompaniment 
of  the  lesion,  and  that  they  are  met  with  in  other  affections  of  the  cord. 


TUMORS   OF   THE   SPINAL   CORD.  619 

A  tumor  situated  in  the  cervical  or  upper  dorsal  region  of  the  cord 
sometimes  gives  rise  to  characteristic  symptoms.  Thus  there  may  be 
dilatation  or  contraction  of  the  pupil  on  one  or  both  sides,  or  one  may 
be  contracted  and  the  other  dilated.  Cough  and  dyspnoea,  vomiting, 
difficulty  of  swallowing,  epileptiform  convulsions,  and  a  remarkable 
slowness  of  the  pulse,  are  sometimes  among  the  phenomena.  But  such 
symptoms  are  by  no  means  invariable.  Many  years  ago  Velpeau '  re- 
ported a  case  of  tumor  of  the  cervical  region  of  the  cord  in  which  none 
of  these  symptoms  were  present.  The  patient,  a  woman  at  thirty -four 
years  of  age,  after  having  experienced  mental  troubles  and  been  ex- 
posed to  bad  hygienic  influences,  suffered  from  convulsive  movements 
of  the  limbs  which  were  not  of  long  continuance.  Shortly  afterward 
the  left  arm  became  the  seat  of  a  severe  pain,  and  she  had  pains  in  the 
head.  The  pain  in  the  arm  increased,  and  little  by  little  she  lost  the 
use  of  the  limb.  Renewed  convulsive  movements  occurred  in  the  in- 
ferior extremities,  and  were  followed  by  complete  paralysis.  When  she 
presented  herself  at  the  hospital  she  had  no  pain  in  the  left  arm,  which 
was,  however,  entirely  paralyzed,  but  which,  nevertheless,  retained  its 
sensibility  almost  unaltered.  Motion  of  the  right  arm,  though  difficult, 
was  still  possible,  but  it  was  the  seat  of  very  severe  pain.  Respiration 
was  normal  but  a  little  weak;  the  pulse  was  frequent,  sometimes  strong, 
but  generally  small  and  regular.  There  was  a  large  and  deep  ulcera- 
tion on  the  sacrum;  the  lower  extremities  were  anasarcous  and  were  de- 
prived of  all  sensation  and  power  of  motion.  The  fecal  matters  and  the 
urine  were  passed  involuntarily  and  unconsciously.  Gradually  she  lost 
the  ability  to  move  the  right  upper  extremity.  She  sank  almost  im- 
perceptibly without  apparent  cause,  and  died  after  having  been  two 
months  and  a  half  in  the  hospital. 

On  post-mortem  examination  numerous  whitish  opaline  plates  were 
found  scattered  over  the  arachnoid,  but  the  principal  lesion  consisted 
of  a  tumor,  which  was  situated  between  the  arachnoid  and  the  cord,  and 
covered  the  entire  anterior  surface  of  the  latter  from  the  sixth  cervical 
pair  of  nerves  to  the  third  dorsal.  This  growth  appeared  to  have  its 
origin  in  the  left  antero-lateral  furrow.  The  anterior  roots  of  the  left 
spinal  nerves  within  its  area  were  so  compressed  that  they  were  shrunk 
to  mere  threads,  and  the  posterior  roots  of  the  same  side  were  also  sub- 
jeoted  to  pressure.  The  right  posterior  roots  were  in  a  normal  condi- 
tion. The  whole  body  of  the  cord  was  flattened  by  this  tumor,  but  the 
left  side  was  especially  in  this  condition.  The  growth  was  cerebriform 
in  appearance,  and  was  thought  to  be  cancerous. 

As  an  example  of  flu- symptoms  resulting  from  a  tumor  occupying 
the  dorsal  region  of  the  cord,  the  following,  from  (  Ulivier,"  is  oited  : 

'  "Observation  rar  unc  maladie  dc  la  moSIle epiniere  tendanl  ;\  demontrer  I'iaolemenl 
ta  functions  <lcs  racines sensitiTM  et  motrieea  dea  oerft,"  Journal  de phy»iologi$  do  IdL 

i^endie,  tome  vi.,  182G,  p.  138. 

*  "Traite  des  maladies  de  la  moelle  epiniere,"  Paris,  ls:)7,  tome  ii.,  p.  -177. 


620  DISEASES   OF   THE   SPINAL   CORD. 

A  woman,  aged  fifty-two,  had  enjoyed  good  health  till  in  1819  she 
began  to  experience  lancinating  pains  in  the  abdomen  and  breast.  Af- 
ter several  months  these  pains  shifted  their  situation  to  the  pelvis  and 
the  lower  extremities,  especially  the  left.  These  limbs  then  became  the 
seat  of  varied  phenomena,  sometimes  being  cold,  at  others  hot,  and 
again  numb  ;  they  were  also  subject  to  the  most  intolerable  itching. 
Then  they  became  by  turns  immovable,  and  were  agitated  by  convulsive 
movements.  Although  she  could  stand,  walking  was  impossible.  Fi- 
nally, in  February,  1821,  they  began  to  atrophy,  and  at  once  lost  all 
sensibility  and  power  of  motion.  Then  these  symptoms  disappeared, 
and  there  only  remained  numbness  and  pains  apparently  starting  from 
the  pelvis  and  traversing  the  nerves.  In  May,  1821,  she  entered  the 
hospital.  At  this  time  the  inferior  extremities  were  rigid,  and  could 
not  be  flexed  without  causing  pain  of  a  very  atrocious  character.  They 
were  insensible  to  all  external  excitations,  but  were  constantly  the  seat 
of  severe  and  lancinating  pains.  There  was,  however,  no  pain  along 
the  vertebral  column,  and  the  general  health  of  the  patient  was  excel- 
lent. 

All  these  symptoms  persisted  till  in  January,  1823,  the  legs  began  to 
be  flexed  on  the  thighs,  and  these  latter  on  the  pelvis,  to  such  an  ex- 
tent that  the  heels  pressed  against  the  buttocks,  and  the  knees  touched 
the  chest.  Forced  extension  of  the  limbs  was  exceedingly  painful,  and 
when  they  were  by  main  strength  extended  they  at  once  returned  to 
their  former  position  as  soon  as  the  traction  was  discontinued.  Two 
months  before  her  death  the  left  wrist  and  right  knee  became  inflamed; 
the  former  suppurated,  and  the  patient  died  six  weeks  afterward. 
Strychnia  had  been  administered,  but  always  aggravated  the  symp- 
toms.    Morphia  gave  no  relief. 

Examination  after  death  showed  the  brain  to  be  healthy.  There 
was  a  band  of  sclerosed  tissue  on  each  side  of  the  cerebellum. 

The  spinal  cord  was  healthy  as  far  down  as  the  tenth  dorsal  verte- 
bra. Here  a  tumor  existed  between  the  two  layers  of  the  arachnoid. 
The  growth  was  oblong,  and  about  two  inches  in  length.  It  was  simi- 
lar in  appearance  to  brain-tissue,  but  firmer.  It  was  not  adherent  to 
the  cord,  but  throughout  its  whole  extent  pressed  on  the  organ,  which 
was  softened  throughout  to  the  consistence  of  a  thin  jelly.  At  the 
most  voluminous  part  of  the  tumor  the  cord  was  so  much  compressed 
that  it  was  almost  cut  in  two,  so  that  there  was  the  appearance  of  two 
cones  with  their  apices  together.  A  careful  examination  showed  that 
in  the  softened  part  no  trace  of  nerve-structure  remained. 

Leyden,1  among  other  interesting  cases,  gives  the  following,  of  tu- 
mor occupying  the  lower  dorsal  region  of  the  cord  : 

The  patient,  a  woman  twenty-nine  years  old,  after  being  delivered 

1  "Klinik  der  Riickenmarkskrankheiten,"  erstar  Band,  Berlin,  1874,  p.  454. 


TUMORS   OF   THE   SPINAL   CORD. 


621 


Fio. 


of  a  dead  child,  became  affected  with  a  pain  in  the  right  leg,  which, 
starting  from  the  foot,  reached  the  knee,  and  finally  settled  in  the  calf. 
She  noticed  at  the  same  time  a  weakness  of  this  leg,  which  prevented 
her  walking  well,  and  eventually  confined  her  to  bed.  These  symptoms 
disappeared,  and  she  remained  well  for  over  three  years,  when  the  right 
leg  again  became  weak,  and  was  the  seat  of  constant  lancinating  pains, 
which  were  aggravated  by  muscular  exercise.  In  April,  1872,  the  left 
leg  was  also  affected  with  similar  pains.  It  soon  became  impossible 
for  her  to  bend  the  knee  or  to  move  the  limb.  All  these  symptoms  in- 
creased until,  in  February,  1872,  she  was  unable  to  walk,  and  there  was 
complete  anaesthesia  in  both  extremities  as  high  as  the  hips.  A  painful 
sensation  of  constriction  was  felt  around  the  body  at  the  umbilicus. 
The  electric  excitability  of  the  right  lower  extremity  was  lessened,  of 
the  left  was  normal.  The  reflex  excitability  of  both  lower  extremities 
was  increased  ;  the  nutrition  was  good.  At  times  they  were  the  seat 
of  strong  contractions. 

By  August,  1873,  the  patient  was  entirely  confined 
to  bed  on  her  back,  and  deprived  of  all  voluntary  move- 
ment of  her  lower  extremities.  There  were,  however, 
often  paroxysms  of  tremor  in  both  feet  so  strong  as  to 
shake  the  whole  body,  and  at  times  powerful  contrac- 
tions of  the  muscles,  drawing  the  thighs  against  the  ab- 
domen, while  the  knees  were  flexed  to  their  utmost  ex- 
tent. The  constricting  pain  around  the  body  was  still 
present. 

In  the  beginning  of  October  the  patient  was  seized 
with  typhus  fever  and  died.  On  examining  the  spinal 
cord  it  was  found  that  a  tumor  existed  on  the  right 
side,  reaching  from  the  seventh  to  the  tenth  dorsal  ver- 
tebra, and  firmly  attached  to  the  dura  mater.  The  en- 
tire length  of  this  growth  was  eighty  millimetres  (a  lit- 
tle over  three  inches).      (Fig.  89.) 

Causes. — Nothing  is  known  relative  to  the  etiology 
of  intni-spinal  tumors  beyond  the  fact  that  they  may 
result  from  the  syphilitic,  scrofulous,  and  cancerous  dia- 
theses, and  from  wounds  and  injuries. 

Diagnosis. — There  are  no  certain  marks  by  which 
we  oan  determine  with   any  greal    degree  of  certainty  'iA'il' 

that  a  tumor  is  compressing  the  spinal  cord.     We  may 
rasped  sik-Ii  to  l>e  the  case  wrhen  the  motor  paralysis  is 

more    marked    on  one   side  of  the  body  than    the  other, 

and  the  anaesthesia  exists  to  a  greater  extern1   on  the 

opposite  side.     The  existence  of  either  syphilis,  sorofula,  or  cancer,  in 

OOnneotion  with  spinal  troubles  not  clearly  referable  to  some  other  dis- 
ease, may  likewise'   excite  the   suspicion    that    a   tumor  exists.      Hut   the 


b£ 


M; 


622  DISEASES   OF   THE   SPINAL   CORD. 

symptoms — paralysis,  hyperesthesia,  anaesthesia,  contractions,  rigid- 
ity, and  spinal  convulsions — are  met  with  in  other  spinal  disorders, 
notably  in  symmetrical  lateral  sclerosis.  The  unilateral  predominance 
of  the  phenomena  is  probably,  on  the  whole,  most  to  be  relied  upon 
as  a  diagnostic  mark. 

Prognosis. — This  is  always  unfavorable.  It  is  less  so  when  a 
syphilitic  origin  can  be  made  out,  and  when  the  tumor  is  situated  in 
the  posterior  or  lateral  portion  of  the  membranes  it  may  be  removed. 
No  others  recover. 

Morbid  Anatomy  and  Pathology. — The  most  common  intra-spinal 
morbid  growths  are  those  which  are  developed  from  the  vertebra?,  and 
they  include  many  syphilitic,  scrofulous,  and  cancerous  tumors.  They 
originate  either  from  the  bones  or  from  the  periosteum.  Formations 
resulting  from  either  of  these  diatheses  may  also  grow  from  the  menin- 
ges or  the  substance  of  the  cord. 

Parasitic  tumors  due  to  either  the  echinococcus  or  the  cysticercus, 
may  also  be  developed  within  the  spinal  canal.  Their  usual  seat  is  in 
the  membranes  ;  and,  according  to  Ollivier,1  the  echinococcus  is  found 
in  the  spinal  cavity  of  women  only. 

Aneurismal  tumors  occasionally  form  in  the  intra-spinal  arteries,  and 
may  compress  the  cord.  Aneurisms  of  the  thoracic  or  abdominal  aorta 
may,  by  pressure,  cause  absorption  of  the  vertebra?,  and  may  thus 
eventually  subject  the  cord  to  their  influence. 

Among  the  other  intra-spinal  tumors  are  the  glioma — a  growth,  the 
seat  of  which  is  especially  in  the  brain  and  spinal  cord,  and  whose  struct- 
ure is  very  similar  to  that  of  sclerosed  nerve-tissue — the  sarcoma,  the 
psammoma,  the  neuroma,  fibroma,  and  myxoma,  and  tumors,  generally 
syphilitic,  developed  from  the  vertebra?. 

'Treatment. — The  attempt  should  always  be  made,  whenever  the  ex- 
istence of  a  tumor  of  the  spinal  cord  is  suspected,  to  effect  its  removal 
by  anti-syphilitic  treatment,  with  iodide  of  potassium  and  mercury. 
The  following  case  will  show  the  advantages  of  following  this  course: 

In  the  summer  of  1869  I  was  requested  to  visit  a  gentleman  who,  I 
was  informed,  Avas  paraplegic  and  subject  to  paroxysms  of  great  suffer- 
ing. On  making  my  examination,  I  found  his  limbs  contracted,  his  re- 
flex excitability  augmented,  and  motor  paralysis  and  anaesthesia  of  both 
lower  extremities.  There  were  intense  pain  in  the  lower  dorsal  region, 
and  violent  spasms  of  the  sphincter  vesica?,  alternating  with  paralysis 
of  it  and  the  bladder.  There  were  also  paroxysms  of  severe  pain  in  the 
head,  and  occasional  attacks  of  delirium.  He  denied  any  syphilitic  infec- 
tion, but,  on  examining  his  head  with  my  hands,  I  found  a  gummy  tumor 
of  the  scalp  over  the  right  occipital  region.  Further  inquiry  and  ex- 
amination revealed  the  existence  of  a  similar  tumor  over  the  leftiaclius. 
I  inferred  that  there  might  be  one  or  more  like  growths  within  the 
:  i:  Trait6  dcs  maladies  dc  la  moellc  6piniere,"  Paris,  1837,  tome  ii.,  p.  549. 


SYPHILIS   OF  THE   SPINAL   CORD   AND    ITS   MEMBRANES.  623 

spinal  canal,  and  I  administered  the  iodide  of  potassium  in  gradually- 
increasing  doses,  with  the  bichloride  of  mercury  in  doses  of  the  six- 
teenth of  a  grain  three  times  a  day.  In  less  than  two  months  every 
symptom  of  disease,  except  a  general  weakness,  had  disappeared. 
The  tumor  of  the  scalp  went  during  the  first  month  ;  that  of  the  arm 
a  week  later.  The  iodide  of  potassium  was  carried  up  to  fifty  grains 
three  times  a  day.  This  patient  continues  in  good  health  up  to  the 
present  time.  Even  if  there  was  not  sufficient  reason  to  diagnosticate 
the  existence  of  an  intra-spinal  syphilitic  tumor,  the  success  of  the 
treatment  can  scarcely  leave  a  doubt  on  the  subject. 

If  this  treatment  fail,  there  is  little  else  left.  When  the  symp- 
toms point  to  compression  of  the  cord  by  a  tumor  situated  either  in 
the  membranes  or  in  the  spinal  canal,  the  growth  may  be  removed  by 
operative  procedure.  This  operation  was  first  successfully  performed 
by  Horsley  on  a  patient  of  Gowers's.1  Since  then,  numerous  opera- 
tions have  shown  that,  under  proper  antiseptic  precautions,  the  arches 
of  several  vertebras  may  be  removed,  the  membranes  opened,  and  the 
cord  searched  for  a  space  of  several  inches  with  comparative  safety. 
In  this  manner  tumors  have  been  removed  in  several  instances. 

As  means  of  mitigating  the  pain  and  spinal  convulsions,  hypoder- 
mic injections  of  morphia  or  atropia,  or  of  both  combined,  may  be 
employed. 


CHAPTER  VIII. 

SYPHILIS    OF   THE    SPINAL   CORD    AND    ITS    MEMBRANES. 

When  compared  with  like  affections  of  the  brain  and  its  mem- 
branes, syphilitic  accidents  of  the  cord  and  its  envelopes  are  certainly 
rare.  Of  course,  this  statement  has  reference  only  to  new  forma- 
tions. As  a  cause  of  many  of  the  affections  descrihed  in  the  fore- 
going chapters,  syphilis  occupies,  if  not  the  first  place,  at  least  one 
v<rv  near  the  front  rank.  Locomotor  ataxia,  for  instance,  is  proba- 
bly in  the  majority  of  instances  of  syphilitic  origin  ;  and  Dr.  Gow- 
ere  has  recently  gone  so  far  as  to  declare  that  in  his  opinion  syphilis 

is  it-  only  cause. 

As  in  the  brain,  neoplasms  of  syphilit LC  origin  arc  known  to  be 
developed  on  the  periphery  of  the  cord  rather  than  in  its  substance, 
in  the  subarachnoid  space  and  on  the  internal  face  of  the  dura  mater. 

Adhesions  of  the  nieinhrancs   to  each   Other  ami    to   the  substance  of 

the  cord    are  thus   induced,  while   this   latter  is   little   by  little  invaded 

by  the  new  formation.    Generally  the  neoplasm  does  not  appear  as  a 
•  British  Medical  Journal,  January  28,  1888. 


624  DISEASES  OF  THE  SPINAL   CORD. 

well-defined  tumor,  but  as  a  substance  analogous  to  that  of  gummata 
diffused  through  the  tissues. 

The  histological  and  macroscopic  characters  are  like  those  which 
are  met  with  in  like  formations  of  the  encephalon.  Instead  of  a  dif- 
fused infiltration,  little  miliary  nodosities  may  be  met  with,  dissemi- 
nated in  the  meninges.     Engelstedt1  has  reported  a  case  of  this  kind. 

Sometimes  there  is  found  at  the  post-mortem  examination  of  syphi- 
litic patients,  who  had  during  life  presented  evidences  of  spinal  trou- 
bles, a  kind  of  deposit  replacing  to  a  certain  extent  the  cellulo-adipose 
tissue  which  lines  the  internal  face  of  the  spinal  canal.  From  this 
there  results  an  intimate  adherence  of  the  dura  mater  with  the  walls  of 
this  canal.  Virehow  has  reported  a  similar  case  observed  in  an  indi- 
vidual who  had  had  multiple  syphilitic  accidents,  and  in  the  last  pe- 
riod of  his  existence  a  painful  rigidity  of  the  neck  and  arms,  which 
supervened  on  paralysis  of  the  upper  extremities.  At  the  autopsy  the 
dura  mater  was  found  considerably  thickened  at  the  height  of  the 
fifth  and  sixth  cervical  vertebra?,  and  adherent  to  the  wall  of  the  canal 
by  a  great  quantity  of  tough  connective  tissue. 

At  other  times  the  exudation  occupies  the  internal  face  of  the  dura 
mater,  and  this  results  in  adhesions  of  the  membranes  to  each  other. 
At  the  same  time  the  adjacent  part  of  the  cord  is  the  seat  of  a  hyper- 
plasia of  the  neuroglia  with  distention  of  the  nerve-structures.  Hue- 
ter  reports  a  case  of  this  kind. 

In  cases  of  syphilitic  patients  who  have  died  after  having  pre- 
sented symptoms  of  a  spinal  affection,  a  simple  softening  of  the  cord 
has  been  discovered.  On  the  other  hand,  there  have  never  been  any 
absolute  proofs  that  pure  myelitis  has  ever  been  developed  through 
the  influence  of  syphilis. 

And  in  a  certain  number  of  cases  the  autopsy  has  never  revealed 
the  slightest  appreciable  lesion  of  the  cord  (Zambaco,  Kussmaul,  Leon, 
Gros,  and  Lancereaux).  Spinal  affections  are  generally  exhibited  at 
an  advanced  period  of  syphilis,  and  in  individuals  who  present  unde- 
niable traces  of  the  diathesis  with  all  the  accompaniments  of  a  more  or 
less  advanced  cachexia.  They  are  characterized  by  pains  localized  in 
the  spine  or  radiating  to  the  limbs,  with  various  derangements  of 
sensibility  (formication,  numbness,  anaesthesia,  etc.).  Little  by  little 
rigidity  of  the  muscles  supervenes,  and  this  is  succeeded  by  temporary 
contractions  and  movements  which  gradually  lose  their  energy,  and 
are  accompanied  with  painful  cramps.  All  these  symptoms,  which  are 
generally  regarded  as  being  due  to  meningitis,  are  subject  to  alterna- 
tions of  amelioration  and  aggravation,  and  eventually  all  phenomena 
of  excitation  give  place  to  paralysis.  This  generally  first  shows  itself 
in  one  of  the  lower  extremities,  and  advances  with  great  rapidity. 
Very  soon  the  opposite  limb  is  attacked,  and  the  paraplegia  becomes 

1  Archiv  der  Heilkunde,  Bund  iv.,  1863,  p.  139. 


SYPHILIS   OF   THE   SPINAL   CORD   AND   ITS   MEMBRANES.  625 

complete.  Often  the  sphincters  alone  are  involved.  It  is  to  be 
noticed  that  the  paralysis  of  sensibility  does  not  keep  pace  with 
that  of  motion,  which,  after  existing  for  a  long  time,  is  supplement- 
ed by  phenomena  of  anaesthesia  or  paresthesia.  Then  there  is  often 
a  period  of  repose.  At  this  period  proper  treatment  may  procure 
for  the  patient  a  gradual  but  nevertheless  satisfactory  cure.  This 
termination  is,  above  all,  to  be  looked  for  when  the  lesion  remains 
confined  to  the  inferior  part  of  the  cord.  The  prognosis  is  much 
less  favorable  when  the  genito-urinary  functions  are  involved.  In 
such  cases  we  ordinarily  find  that  sooner  or  later  cutaneous  trophic 
troubles  are  developed  over  the  sacrum — purulent  cystitis,  etc. — with 
all  their  consequences.  Hectic  fever  is  excited,  and  the  patient  dies 
greatly  emaciated. 

When  syphilitic  lesions  affect  the  tipper  part  of  the  cervical  region 
of  the  cord,  patients  are  exposed  to  still  greater  dangers.  In  such 
cases  the  symptoms  are  very  rapidly  developed,  for  the  paralysis 
involves  all  the  muscles  of  the  trunk,  including  the  respiratory  appa- 
ratus. The  disease,  in  fact,  follows  a  course  analogous  to  that  of 
acute  ascending  paralysis.  In  such  instances  a  specific  treatment 
instituted  opportunely  may  still  be  sufficient  to  save  the  life  of  the 
patient,  but  cannot  effect  a  complete  cure.  The  tissues  which  have 
been  infiltrated  with  the  syphilitic  exudations  undergo  a  veritable 
modular  retraction  and  alteration,  to  which  there  are  sometimes  add- 
ed secondary  ascending  and  descending  degenerations.  When  the 
secondary  degeneration  affects  the  posterior  columns,  the  paralysis 
may  be  replaced  by  certain  manifestations  of  tabes  dorsalis,  but  this 
syphilitic  ataxia  i3  not  to  be  confounded  with  ordinary  locomotor 
ataxia. 

In  the  cases  of  those  patients  in  whom  at  the  autopsy  appreciable 
alterations  of  the  marrow  are  not  found,  the  spinal  affection  has 
generally  followed  a  subacute  course.  It  then  greatly  resembles 
the  acute  ascending  paralysis  of  Landry.  Sometimes  its  real  charac- 
ter is  recognized  as  being  like  that  which  is  exhibited  at  an  early 
period  of  syphilis,  in  the  course  of  the  first  year  after  contamina- 
tion. Ordinarily  it  is  not  preceded  by  any  prodromatic  symptoms, 
hut  it  is  sometimes  the  case  that  a  very  short  time  after  the  devel- 
opment of  the  paralysis  the  affected  limbs  are  the  seat  of  vague 
pains.  The  paralysis  begins  in  the  lower  extremities,  and  is  com- 
plete after  a  few  "lays.  It  is  accompanied  by  a  certain  degree  of 
weakness   of   (he  bladder,  which    is   manifested   either   by  incontinence 

or  retention  of  urine.  After  the  second  week  the  patient  is  confined 
to  his  bed,  and  in  a  period   relatively  short   he  succumbs  to  septic 

infection.  Therapeutics  can  avail  nothing  against  this  form  of  syphi- 
litic myelitis. 

41 


G26  DISEASES   OF   TUE   SPINAL   CORD. 

CHAPTER   IX. 

SYRINGOMYELIA. 

It  is  only  within  the  past  few  years  that  the  attention  of  neurolo- 
gists has  heen  drawn  to  the  study  of  the  symptoms  produced  by  the 
formation  of  abnormal  cavities  within  the  spinal  cord.  That  such 
cavities  were  of  frequent  occurrence  has  been  known  for  many  years, 
but  recently  the  researches  of  Schultze  in  1882,  *  and  again  in  1885,2 
on  the  pathology  of  the  disease,  and  further  contributions  to  the 
clinical  study  of  the  disease  by  Baumlei,3  Buhl,4  Starr,6  Van  Giesen,6 
Jeffries,7  and  others,  show  that,  at  least  in  many  instances,  this  dis- 
ease may  be  diagnosticated  with  accuracy. 

Symptoms. — As  the  disease  usually  begins  in  the  cervical  or  upper 
dorsal  regions  of  the  cord,  the  first  symptoms,  under  those  circum- 
stances, will  be  observed  in  the  upper  extremities. 

The  motor  symptoms  are  progressive  paralysis  followed  by  atro- 
phy of  the  affected  muscles.  Sometimes  whole  groups  of  muscles 
supplied  by  one  nerve  are  paralyzed  simultaneously  ;  again  one  muscle 
after  another  may  become  affected.  Fibrillary  muscular  twitchings 
are  frequently  observed,  not  only  in  the  paralyzed  muscles,  but  also  in 
those  muscles  which  are  about  to  become  paralyzed.  Contractions  of 
the  unaffected  muscles  often  follow,  thus  producing  various  deformi- 
ties, the  most  common  of  which  is  the  main  en  griffe.  The  electrical 
reactions  show  a  quantitative  decline  consequent  upon  the  diminished 
volume  of  muscular  tissue,  and  the  polar  degenerative  reactions  may 
or  may  not  be  present.  If  the  motor  cells  in  the  anterior  horn  of  gray 
matter  are  involved  in  the  destructive  process,  the  polar  degenerative 
reactions  can  readily  be  obtained  ;  otherwise  they  can  not  be. 

The  superficial  reflexes  are  generally  abolished  ;  the  knee-jerk  is 
either  normal  or  else  slightly  exaggerated. 

As  far  as  the  motor  symptoms  are  concerned  up  to  this  point,  they 
differ  but  little  from  those  previously  described  under  the  heading  of 
progressive  muscular  atrophy.  In  time,  however,  as  the  disease  ex- 
tends so  as  to  destroy  a  greater  area  of  the  cord,  and  more  pressure  is 
exerted  on  the  surrounding  tracts  by  the  fluid  within  the  cavity,  the 
motor  phenomena  invade  the  lower  extremities.     These  become  weak  ; 

1  Vircbow's  "Archives,"  vol.  lxxxvii. 

2  Ibid.,  vol.  cii. 

3  Deutsche  Archiv  fur  klin.  Med.,  Bd.  xl,  1886. 
'  Are/iiv  fur  gen.  Med.,  July,  1889. 

5  Am.  Journ.  Med.  Sciences,  May,  1888. 

6  Journ.  Nerv.  and  Ment.  Dis.,  July,  1889. 
1  Ibid.,  September,  1890. 


SYRINGOMYELIA.  627 

stiffness  of  the  muscles  supervenes  ;  the  patellar  tendon  reflex  is  exag- 
gerated ;  and  the  ankle  clonus  can  frequently  be  obtained.  Romberg's 
symptom,  or  the  inability  to  stand  upright  with  the  feet  close  together 
and  with  the  eyes  closed,  is  sometimes  observed.  These  symptoms, 
with  the  exception  of  the  last  one,  are  identical  with  those  produced 
by  inflammation  of  the  lateral  pyramidal  tracts,  and  their  presence  in 
syringomyelia  indicates  that  that  tract  has  become  implicated  either 
from  pressure  or  else  from  being  involved  in  the  diseased  process. 

The  sensory  symptoms  are  not  confined  to  the  regions  in  which  the 
muscular  paralysis  exists.  The  sensations  of  pain  and  temperature 
are  abolished,  while  the  sense  of  touch  is  preserved.  There  will 
be  absolute  anaesthesia  for  heat  and  cold,  for  pricking  the  skin  and 
irritating  it  by  strong  electrical  currents  over  the  affected  areas,  and 
yet  the  individual  can  distinctly  feel  that  the  parts  are  touched,  and 
can  usually  locate  with  considerable  accuracy  the  spot  where  the 
touch  was  felt.  Jacquet l  reports  one  case  in  which  the  tactile  sense 
was  destroyed  together  with  the  senses  of  pain  and  temperature. 
Pricking,  stinging,  and  burning  sensations  are  frequently  complained 
of.  The  trophic  and  vaso-motor  symptoms  are  not  always  well  marked. 
Usually  the  affected  limbs  are  cold  and  blue,  and  generally  the  secre- 
tion of  sweat  is  diminished  or  abolished.  Cuts  and  abrasions  of  the 
-kin  heal  with  difficulty,  and  ulcers  and  bed-sores  which  sometimes  ap- 
pear are  not  amenable  to  the  usual  forms  of  treatment.  The  finger 
nails  become  brittle,  and  occasionally  dislocations  of  joints  and  fract- 
ures of  bones  have  occurred  similar  to  those  observed  in  locomotor 
ataxia. 

Causes. — Little  is  known  in  regard  to  the  etiology  of  this  disease. 
In  Mime  cases  it  seems  to  follow  from  injuries  of  the  spinal  cord,  in 
others  it  develops  in  apparently  healthy  subjects  who  are  not  suffering 
from  any  congenital  taint  or  predisposition. 

Diagnosis. — Syringomyelia  may  be  confounded  with  hysteria,  mul- 
tiple neuritis,  progressive  muscular  atrophy,  pachymeningitis,  and  pos- 
Bibly  with  anaesthetic  leprosy. 

Prom  hysteria,  syringomyelia  can  usually  be  differentiated  by  the 
history  of  the  case,  the  presence  in  the  latter  disease  of  the  reactions 
of  degeneration,  of  fibrillary  twitchings,  and  by  the  early  appearance 
of  muscular  atrophy  and  the  well-marked  trophic  and  vaso-motor 
changes. 

In    multiple    neuritis   the    Dervefl  are    tender   and   arc  painful  under 

-nre,  the  tactile  Bense  is  abolished  with  the  other  varieties  of  Ben* 

Bation,  the  disturbances  of  sensibility  correspond  in  location  with  the 

disorders  of  motility,  and  there  is  usually  a  great  deal  of  pain  in  the 

affected    members  which   is  augmented  both  by  active  and   passive 

motion. 

1  Oompt  rmd.  hebdom,  toe  eh  Mb/.,  Paris,  tome  i 


628  DISEASES   OF  THE   SPINAL   CORD. 

In  progressive  muscular  atrophy  there  are  no  abnormities  of  sen- 
sibility, no  tendency  to  the  formation  of  ulcers  and  bed-sores,  and 
no  diminution  in  the  excretion  of  sweat. 

Cervical  pachymeningitis'  can  be  distinguished  by  the  severe  ten- 
derness and  pain  over  the  region  of  the  inflammation,  and  by  the 
absence  of  the  symptoms  of  disease  of  the  central  gray  matter  of  the 
cord. 

Anaesthetic  leprosy,  though  of  very  rare  occurrence,  at  least  in 
this  country,  bears  some  resemblance  to  syringomyelia.  In  one  variety 
of  the  former  affection — -that  is,  the  lepra  nervorum — the  senses  of  pain 
and  temperature  may  be  abolished  while  the  sense  of  touch  remains 
intact.  If  there  are  no  accompanying  skin  lesions  the  differential 
diagnosis  may  be  difficult  or  impossible. 

Prognosis. — No  case  of  a  cure  has  yet  been  recorded.  The  patient 
either  dies  from  exhaustion  or  else  the  disease  in  its  progress  involves 
the  upper  regions  of  the  cord,  the  perfect  integrity  of  which  is  essen- 
tial to  life. 

Morbid  Anatomy  and  Pathology, — The  formation  of  abnormal 
cavities  within  the  spinal  cord  may  depend  upon  any  one  of  sev- 
eral morbid  conditions.  In  childhood,  hydromyelia,  or  the  disten- 
tion of  the  central  canal  by  fluid,  sometimes  occurs.  Gowers '  is  in- 
clined to  regard  this  condition  as  similar  in  nature  to  syringomyelia, 
and  believes  that  both  conditions  are  congenital.  Scbultze,8  on  the 
contrary,  while  admitting  that  a  congenital  defect  is  responsible  for 
hydromyelia,,  considers  that  syringomyelia  may  develop  in  a  healthy 
cord  free  from  any  hereditary  predisposition.  I  have  seen  specimens 
of  the  former  disease  in  which  the  tissues  surrounding  the  dilated 
canal  were  healthy,  the  epithelial  lining  being  plainly  visible  under 
the  microscope.  Syringomyelia  may  develop  from  hajmorrhage  into 
the  cord,  from  softening  of  the  cord  followed  by  absorption,  from  sar- 
coma, and  from  gliomatous  tumors.  The  latter  is  by  far  the  most 
common.  According  to  Schultze,  it  begins  with  an  infiltration  of 
gliomatous  cells,  usually  in  the  neighborhood  of  the  central  canal,  and 
confines  itself  almost  entirely  to  the  gray  matter.  The  pressure  thus 
brought  to  bear  upon  the  surrounding  tissues  gradually  destroys  them. 
The  gliomatous  mass  thus  formed  eventually  breaks  down  and  be- 
comes absorbed,  leaving  a  cavity  the  walls  of  which  are  lined  with 
connective  tissue.  The  accompanying  illustrations,  Fig.  90  and  Fig. 
91  (after  Yan  Gieson),  show  the  position  of  the  cavity  in  the  cord  in 
his  case,  and  also  sections  of  the  cord  made  at  different  levels. 

The  infiltration  is  not  always  of  a  gliomatous  nature.  Berkley 3 
reports  a  case  in  which  there  was  a  dense  hyaline  infiltration  which 

1  "  Disease.?  of  the  Nervous  System,"  p.  422. 

2  ZeiUehrift  fur  klin.  Med.,  No.  13,  1887. 

3  Brain,  London,  1889-1890,  vol.  xlviii. 


Fm.  HO.— Syringomyelia.    (Van  Giesen.) 


''''■■  W.    Bj  rugomyelio,    (Van  Q 


PSEUDO-IIYPERTROPHIC   PARALYSIS.  629 

seemed  to  exude  from  the  blood-vessels,  which  after  absorbing,  and  to 
a  great  extent  destroying,  the  surrounding  tissue,  broke  down  itself 
and  was  absorbed,  leaving  a  cavity.  Chemical  tests  showed  that  the 
exudation  was  hyaline.  He  refers  to  Huten,  Steudener,  and  Langhaus 
as  having  observed  similar  pathological  changes. 

In  some  instances  the  cavity  in  the  cord  is  undoubtedly  a  congeni- 
tal defect.  Van  Gieson  '  reports  a  case  of  this  kind.  But  I  am  in- 
clined to  the  opinion  that  the  majority  of  cases  develop  in  subjects 
whose  spinal  cords  were  previously  normal. 

Treatment. — There  is  very  little  to  be  said  on  this  subject.  The 
very  nature  of  the  disease  precludes  the  possibility  of  a  cure  being 
effected.  The  most  that  can  be  done  is  to  relieve  the  symptoms  of 
the  disease  and  to  make  the  patient  as  comfortable  as  possible. 

Electrization  of  the  paralyzed  muscles,  rest,  and  a  general  tonic 
treatment,  together  with  a  full  nourishing  diet,  will  prove  of  some 
service,  and  may  retard  the  progress  of  the  disease. 


CHAPTER   X. 

PSEUDO-// YPER  TROPHIC  PARA L  TSIS. 

In'  the  early  editions  of  this  work  I  considered  this  disease  under 
the  head  of  hypertrophy  of  muscular  connective  tissue,  although  treat- 
ing of  it  as  one  of  the  affections  of  the  motor  and  trophic  cells  of  the 
(■id.  liut  this  view  must  now  be  abandoned,  since  the  evidence  of 
later  years  practically  points  to  this  disease  as  being  essentially  a 
myosis.  The  clinical  similarity  of  this  affection  with  diseases  depend- 
ent upon  lesions  of  the  central  nervous  system  is  so  obvious  that  no 
apology  is  necessary  for  inserting  it  in  its  present  position. 

Although  previously  noticed,  the  first  to  thoroughly  investigate  the 
condil  ion  was  Duchenne,'  who  described  it  under  the  name  oiparapl&gie 
hypt  rtrophiqtu  de  r>  nfance  de  causi  ckr&brale.  He  has  since  designated 
it  paralysis  pseudo-hypertrophique,  <>"  myo-seVerosigxie?  Jaccoud4 
calls  it  sdri'nsf  t.-nisriihtirr  />/•<>>/ rtssive  (progressive  muscular  sclero- 
sis). Dr.  Foster  terms  it  paralysis  with  apparent  muscular  hypertro- 
phy, and  Barth*  fatty  muscular  atrophy. 

1  ./.>",-,/.  Kerv.  mi'/  M.ni.  hi-,.,  July,  1889, 

*  "  De  ['electrisation  localise,"  etc,  Paris,  1881,  p.  •"•">•'!. 
9  Archives  QSniraies,  etc.,  1808. 

*  Cfp.  eit 

*  Lancet,  Uaj  8,  1869. 

•"Beitrage  ror  Kenntnlsi  der  atrophia  muaculorem  lipomatosa,"  Archiv  der 
/.aw/',  1871,  p.  120. 


630  DISEASES   OF   THE   SPINAL   CORD. 

Symptoms. — The  first  symptom  observed  is  weakness  in  the  lower 
extremities,  which  causes  an  inability  to  stand  steadily,  or  to  walk 
without  stumbling  or  falling.  The  legs  are  separated  widely  in  stand- 
ing or  walking,  and  thus  a  peculiar  character  is  given  to  the  gait,  which 
somewhat  resembles  that  of  a  duck. 

Very  soon  an  enlargement  of  the  calf  of  one  of  the  legs  is  perceived, 
the  other  before  long  is  affected,  and  then  the  muscles  of  the  thighs 
and  gluteal  region  become  involved. 

As  the  child  stands  or  walks,  a  remarkable  incurvation  of  the  spine 
in  the  lumbo-sacral  region  is  perceived,  so  that  if,  as  Duchenne  remarks, 
a  plumb-line  be  allowed  to  fall  from  the  most  posterior  part  of  the 
spinous  process  of  a  vertebra,  it  passes  far  behind  the  sacrum.  He 
considers  this  phenomenon  to  be  due  to  weakness  of  the  erector  muscles 
of  the  spine.  The  muscles  of  the  trunk  may  become  involved,  as  may 
also  those  of  the  upper  extremities — the  deltoids  being  the  first  affected 
in  the  majority  of  cases,  and  the  progress  being  much  slower  than  in 
the  lower  extremities. 

"With  the  advance  of  the  hypertrophy  the  paralysis  becomes  more 
strongly  marked,  and  finally  the  child  is  confined  to  the  recumbent 
posture.  Distortions  from  disturbance  of  muscular  equilibrium  may 
take  place,  and  the  attempt  at  flexion  or  extension  becomes  painful. 

Occasionally  the  skin  over  the  affected  parts  presents  a  peculiar 
mottled  appearance,  such  as  would  be  produced  in  the  healthy  skin  by 
exposure  to  cold. 

After  a  period  which  varies  in  duration  from  two  to  five  or  six 
years,  the  hypertrophied  limbs  may  begin  to  diminish  in  size,  and 
eventually  they  put  on  very  much  the  appearance  exhibited  in  infantile 
spinal  paralysis.  This  does  not  appear  to  be  a  constant  occurrence, 
but  is  markedly  exhibited  in  a  case  now  under  my  care.  Sometimes 
the  muscles  which  are  attacked,  as  the  disease  advances  from  the  lower 
extremities,  do  not  become  hypertrophied,  but  on  the  contrary  diminish 
in  volume  as  in  infantile  spinal  paralysis.  We  thus  have  in  the  same 
individual  some  muscles  paralyzed  with  coexistent  hypertrophy,  while 
others  are  paralyzed  and  atrophied. 

Electric  contractility  is  always  lessened,  both  to  the  induced  and 
to  the  primary  currents,  but  the  polar  degenerative  reactions  are  never 
observed.  The  knee-jerk,  from  primary  changes  in  the  muscles,  is 
gradually  diminished  and  is  finally  abolished. 

The  course  of  the  disease  is  slow,  its  average  duration  being  about 
five  or  six  years.  As  it  advances,  there  are  symptoms  indicating  loss 
of  mental  power,  and  cerebral  disturbance  is  sometimes  also  indicated 
by  ocular  troubles  and  pain  in  the  head. 

Death  takes  place  by  the  respiratory  muscles  becoming  implicated, 
by  exhaustion,  or  by  some  intercurrent  affection. 

Weir  Mitchell,  in  the  Philadelphia  Photof/raphic  Review,  for  1871, 


PSEUDOHYPERTROPHIC   PARALYSIS.  631 

reported  a  case  which  has  recently  been  reexamined  by  Dr.  George 
S.  Gerhard.1  The  most  remarkable  feature  of  the  case,  that  of  a  boy 
now  thirteen  years  old,  is  that  the  tongue  and  all  the  facial  mus- 
cles, but  particularly  the  temporals,  are  hypertrophied.  His  speech  is 
altered  from  the  enlargement  of  the  tongue,  and  he  has  some  difficulty 
in  taking  his  food.  There  is  also  a  somewhat  more  than  normal  car- 
diac impulse.  As  regards  the  hypertrophy  of  the  facial  muscles  this 
case  is  remarkable,  and  would  be  unique,  but  for  the  occurrence  of  a 
like  condition  in  a  case  of  my  own,  in  which  the  left  side  of  the  face 
is  hypertrophied. 

In  the  case  which  came  under  my  notice  March  7,  1871,  the  patient, 
a  boy  seven  years  old,  exhibited  a  great  disinclination  to  learn  to  walk. 
At  three  years  of  age  he  could  not  stand  longer  than  a  few  seconds, 
and  even  for  this  time  he  was  obliged  to  spread  the  legs  apart  and  to 
hold  on  to  some  article  of  furniture.  It  was  not  noticed  till  he  was'five 
years  old  that  his  legs  were  larger  than  was  natural.  The  hypertrophy 
began  in  the  right  calf,  then  attacked  the  left,  and  then  the  glutei  mus- 
cles, before  affecting  the  muscles  of  the  thighs.  The  upper  extremi- 
ties are  as  yet  unaffected,  but  the  spinal  curve  is  very  evident.  The 
accompanying  woodcuts  (Figs.  92  and  93)  give  a  posterior  and  profile 
view  of  this  boy,  from  photographs.  He  was  unable  to  stand  alone 
while  the  photographs  were  being  taken,  but  the  spinal  curve  is  well 
shown,  and  the  positions  are  those  he  spontaneously  assumed.  He  died 
in  the  spring  of  1875,  with  pneumonia,  having  been  for  the  previous 
three  years  unable  to  stand  or  even  sit.  The  muscles  of  the  upper  ex- 
tremities  were  paralyzed  for  two  years  before  his  death,  but  under- 
went rapid  atrophy  instead  of  enlargement. 

Another  case,  that  of  a  bright,  intelligent  boy,  six  years  of  age, 
was  broughl  to  me  May  3,  1871,  at  the  suggestion  of  my  friend  Dr. 
Trask,  of  Astoria,  who  accompanied  the  patient.  Several  months  pre- 
vious 'he  child  hid  been  noticed  to  fall  frequently  while  at  play  in 
the  bouse,  and  to  Bhow  weakness  in  the  lc<_rs  when  ascending  a  stair- 
case.      The  parents  were  unable  to  account  for  this  debility,  for.  as  the 

father  assured   me,  the  Legs  were  exceedingly  well  developed.     As 

the  boy  stood  in  my  consulting-room,  I  observed  that  he  separated  his 
l«u-  to  a  greater  than  usual  distance,  and  that  as  he  walked  he  also 
kept  them  far  apart,  ami  that  his  gait  was  Btaggering.      As  somi  as  hi> 

trousers  were  removed  I  at  once  perceived  the  nature  of  his  disease, 
for  the  calves  of  both  legs  were  hypertrophied  to  an  enormous  extent, 

and  the  ineiirv  at  ion  of   the  spine  was  well   marked.      The   elect  ro-mus- 

cular  contractility  was  almost  entirely  abolished  in  the  gastrocnemii 
and  solei  muscles,  and  notably  lessened  in  the  musoles  of  the  thighs, 
the  gluteal  region,  and  the  back.    These  latter  were  not  hypertrophied. 

On   the   contrary,   they    appeared    to    be    rather   under  than   above  the 
1  " Pseudohypertrophic  Paralysis,11  Philadelphia  Medical  Timet,  Oct  Lfl,  1875,  u.  •"■! 


632 


DISEASES   OF   THE   SriNAL   CORD. 


normal  size,  and  they  were  in  a  very  decided  paretic  condition.  Thus, 
when  I  requested  him  to  cross  one  leg  over  the  other  as  he  sat  on  a 
chair,  he  was  unable  to  do  so  without  seizing  hold  of  the  leg  with  his 


Fig.  92. 


Fig.  93. 


hands  and  thus  assisting  with  their  strength,  and,  as  he  lay  at  full 
length  on  his  back  on  the  floor,  he  could  not  draw  up  his  legs  without 
great  trouble,  though  he  could  flex  the  thighs  with  readiness. 

On  measuring  the  calves  at  their  greatest  dimensions,  I  found  the 
right  to  have  a  circumference  of  twelve  and  a  quarter  inches,  and  the 
left  of  eleven  and  a  half  inches.  The  right  thigh,  at  its  point  of 
greatest  circumference,  measured  but  eleven  and  a  quarter  inches,  and 
the  left  ten  and  three-quarters  inches.  I  saw  this  patient  again  in  the 
course  of  two  months.     The  paralysis  of  the  lower  extremities  had  in- 


PSEUDO-HYPE RTROPHIC   PARALYSIS.  633 

creased  to  such  an  extent  as  to  cause  walking  to  be  very  difficult.  At 
every  step  he  lifted  the  thigh  almost  to  the  line  of  a  right  angle  with 
the  body,  for  he  had  no  power  to  raise  the  foot.  The  flexors  of  the 
thigh,  upon  the  pelvis,  did  not  therefore  appear  to  be  much  weakened. 
The  calves  were  of  about  the  same  size  as  before.  The  upper  extremi- 
ties were  still  unaffected. 

I  did  not  see  this  case  again  for  nearly  two  years.  The  paralysis 
had  then  so  far  extended  as  to  render  walking  impossible,  but  the  arms 
were  still  strong,  and  bv  their  means  the  patient  dragged  himself  along 
over  the  floor.  The  calves  had  diminished  in  size,  and  the  extensor 
muscles  of  the  foot  had  become  atrophied  to  such  an  extent  as  to  allow 
of  the  permanent  elevation  of  the  heels  by  the  uncompensated  action 
of  the  still  incompletely-paralyzed  gastrocnemii  and  solei.  The  thighs 
were  now  hypertrophied,  as  were  also  the  glutei  muscles. 

Accurately  measured,  the  circumference  of  the  calves  was,  for  the 
right,  eight  and  a  half  inches,  a  loss  of  three  and  three-quarters  inches  ; 
and  for  the  left,  eight  and  a  quarter  inches,  a  loss  of  three  and  a  quarter 
inches.  On  the  other  hand,  the  right  thigh  measured,  at  its  largest 
part,  fifteen  inches,  an  increase  of  three  and  three-quarters  inches;  and 
the  left  fourteen  and  three-quarters  inches,  an  increase  of  four  inches. 

I  saw  this  patient  again  in  the  summer  of  1874,  a  year  after  the  last 
visit,  when,  in  order  to  allow  of  his  wearing  a  shoe,  I  divided  the  right 
tendo-achillis,  with  the  result  of  bringing  down  the  heel  and  perma- 
nently relieving  the  extreme  condition  of  talipes  equinus  which  existed. 
The  calves  had  undergone  still  further  atrophy,  and  the  thighs  were 
likewise  beginning  to  shrink.  There  was  a  slight  disposition  to  a  con- 
traction of  the  flexors  of  the  thighs,  and  the  upper  extremities  were  be- 
coming paretic. 

A  year  subsequently  (duly,  1875)  I  again  saw  this  patient.  He  had 
then  been  using  a  steel  apparatus,  which  enabled  him  to  stand,  or  rather 
the  apparatus  stood,  and,  being  strong,  supported  the  completely-para- 
lv/.i'l  patient.  The  calves  now  measured,  the  right  eight  inches,  and 
the  left  eight  and  a  quarter  inches  in  circumference — a  loss  from  the 
first  measurements  of  four  and  a  quarter  inches  and  three  and  a  quarter 
inches  respectively.  The  thighs  had  also  lost  greatly  from  their  hyper- 
trophied condition  of  two  years  before.  The  right  now  measured.  at 
its  largest  part,  ten  and  a  half  inches,  a  loss  of  five  inches,  and  the  left 
ten  inch*    .  a  loss  of  four  and  three-quarters  inches. 

The  upper  extremities  were  decidedly  weaker  than  they  were  a  year 
ago,  but  there  was  as  yet  do  hypertrophy.  The  patient  could  not  even 
sit  without  support,  and  there  was  notable  weakness  of  the  muscles 
which  maintain  the  ereol  p  isition  of  the  head. 

Throughout  the  whole  of  the  period  during  whioh  this  patient  has 
been  under  my  observation,  the  mind  has  remained  char,  and  the  gen- 
eral health  has  been  exoellent,  circulation,  respiration,  digestion,  and 


634 


DISEASES   OF   THE   SPINAL   CORD. 


Fig.  94. 


urination,  all  being  well  performed.     The  cutaneous  tactile  sensibility 
and  the  sensibility  to  pain  have  not  been  in  the  least  weakened. 

While  these  pages  are  going  through  the  press,  I  have  again  (De- 
cember 2,  1875)  examined  this  patient,  whose  general  health  began  to 
show  signs  of  giving  way.  To  my  astonishment,  a  feature  presented 
itself  which  thus  far  is  entirely  exceptional.  A  second  stage  of  hyper- 
trophy is  going  on  ;  the  calves  now  measure,  the  right  ten  inches,  and 
the  left  ten  and  a  quarter.  The  thighs  were  not  measured,  but  were 
very  considerably  larger  than  when  I  last  saw  them  ;  and  the  father, 
a  very  intelligent  gentleman,  said  that  the  enlargement  in  the  lower 
extremities  had  been  going  on  for  two' or  three  months.  The  left 
side  of  the  face  was  decidedly  larger  than  the  right.  The  patient 
was  still  unable  to  walk,  stand,  or  sit  alone,  but  was  comparatively 

strong  in  the  arms,  and  in  good  gen- 
eral health.  His  mind  was  remark- 
ably bright. 

At  all  my  examinations  except  the 
last  two,  I  removed,  by  means  of  Du- 
chenne's  trocar,  portions  of  the  hy- 
pertrophied  and  atrophied  muscles, 
the  results  of  the  examination  of 
which  will  be  given  under  the  head 
of  the  morbid  anatomy. 

Quite  recently  Dr.  E.  B.  Richard- 
son, Of  Mount  Sterling,  Kentucky, 
has  given  me  the  details,  with  photo- 
graphs, of  an  interesting  case  of  the 
disease  under  notice.  The  patient,  a 
boy,  is  eight  years  of  age,  of  average 
intelligence,  though  not  capable  of 
prolonged  mental  exertion.  The  dis- 
ease is  of  several  years'  duration,  and 
he  is  slowly  getting  worse.  His  loco- 
motion is  peculiar  ;  usually  he  walks 
with  his  hands  grasping  the  front  of 
the  thighs,  and  his  legs  are  drawn  up 
suddenly,  as  if  with  strings  fastened 
to  his  back.  In  ascending  a  stair- 
case, he  does  so  with  his  hands  on  his 
thighs,  and  the  same  foot  is  always 
advanced  first,  and  not  each  alter- 
nately. If  sitting  down,  he  raises 
himself  by  clasping  the  thighs  strongly  ;  otherwise  he  cannot  get 
up  at  all. 

The  boy's  father  is  a  strong  and  robust  man  ;  his  mother  is  delicate, 


PSEUDO-IlYPERTKOrniC   PARALYSIS. 


635 


Fro.  »5. 


and  has  had  seven  children,  of  whom  three  are  younger  than  the  pa- 
tient. In  two,  at  least,  of  the  other  children  there  is  some  enlargement 
of  the  gastrocnemii  mus- 
cles and  a  general  ema- 
ciated appearance  of  the 
upper  extremities.  With 
the  birth  of  the  last  child 
the  mother  had  puerperal 
mania,  and,  June  23d,  had 
not  fully  recovered.  She 
had  a  Bister  and  a  brother 
who  were  insane,  and  there 
is  incurable  insanity  in 
collateral  branches  of  her 
family. 

Pig.  94,  from  a  photo- 
graph, shows  well  the  atro- 
phy of  the  trunk  and  up- 
per extremities,  the  spinal 
curve,  and  the  hypertro- 
phy of  the  gastrocnemii 
muscles.  Fig.  95  exhib- 
its the  remarkable  position 
assumed    by   the    patient 


Fig.  97. 


Fig.  96. 


just  as  he  is  aboul  to  rise  fn>m  the  Bitting  posture.     The  atrophy  of 
the  muscles  of  the  chesl  and  abdomen  is  also  Bhown. 

The  postures  assumed  when  an  attempl   is  made  to  change  from  a 


(536  DISEASES   OF   THE   SPINAL   CORD. 

horizontal  to  a  vertical  position  are  characteristic.  The  movements 
are  slow  and  labored,  and  are  performed  with  difficulty.  When  the 
patient  is  extended  at  full  length  upon  his  back  and  is  then  told  to 
arise,  he  slowly  gets  upon  his  hands  and  knees,  then — still  keeping  his 
hands  upon  the  floor — he  gradually  brings  his  legs  into  a  vertical  posi- 
tion (Fig.  98).  The  hands  are  then  placed,  one  after  the^  other,  upon 
the  knees,  when,  by  "  climbing  up  the  thighs,"  as  it  is  termed,  the 
trunk  is  slowly  raised  to  an  upright  position  (Fig.  97). 

Causes. — The  disease  is  one  which  is  almost  entirely  confined  to 
children,  and  boys  are  more  liable  than  girls.  Nevertheless,  it  is  not 
a  disease  peculiar  to  very  early  infancy.  "Of  thirteen  cases  observed 
by  Duchenne,  six  are  stated  to  have  begun  in  first  infancy,  while  in 
seven  the  inception  occurred  at  from  two  to  ten  years.  Cases  have 
also  been  reported  as  occurring  in  adults.  From  a  table  containing  an 
analysis  of  forty-one  cases  given  by  Dr.  "Webber,  in  his  paper  already 
cited,  it  appears  that  in  one  case  the  patient  was  twenty-six  when  the 
disease  began,  in  one  a  few  years  under  forty,  and  in  one  about  twenty- 
eight. 

Duchenne  expresses  the  opinion  that  a  hereditary  tendency  some- 
times exists,  and  this  appears  to  be  the  fact.  Of  the  cases  analyzed 
by  Poore,  in  two,  a  maternal  uncle  and  aunt  had  the  disease  ;  in  one, 
three  maternal  uncles  and  aunts  were  affected  ;  in  one,  one  maternal 
uncle  and  one  half-uncle  ;  in  one,  three  maternal  half-brothers  ;  and  in 
one,  a  maternal  half-brother,  three  maternal  uncles,  and  other  members 
on  the  mother's  side. 

The  disease  does  not  appear,  therefore,  to  be  transmitted  directly 
from  parent  to  offspring,  but  is  a  marked  example  of  atavism.  The 
descent  is  always  from  the  mother's  side. 

As  to  exciting  causes,  little  or  nothing  is  known.  In  none  of  my 
cases  could  any  reasonable  explanation  of  its  etiology  be  given.  There 
is  some  reason  for  ascribing  it  occasionally  to  exposure  to  cold  and 
dampness,  and  to  antecedent  febrile  diseases. 

Diagnosis. — The  only  affection  at  all  resembling  that  under  consid- 
eration is  simple  muscular  hypertrophy  due  to  an  excessive  supply  of 
blood  being  sent  to  a  part  of  the  body.  The  histories  and  phenomena 
of  the  two  disorders  are,  however,  so  very  different,  that  I  do  not  see 
how  any  error  can  arise  in  making  a  diagnosis  between  them.  Never- 
theless, it  is  tolerably  certain  that  mistakes  on  this  point  have  been 
made.  Thus,  such  cases  as  the  one  reported  by  Mr.  Maunder,'  which 
was  clearly  one  of  muscular  hypertrophy  possessing  no  analogies  with 
the  disease  under  consideration,  have  to  my  knowledge  been  regarded 
as  instances  of  the  disease  under  notice. 

Duchenne,8  under  this  head,  gives  very  elaborate  directions  for  the 

1  Medical  Times  and  Gazette,  March  27,  18G9. 

2  Op.  cit.,  and  "De  l'electrisation  localise,"  troisieme  Edition,  Paris,  18*72,  p.  608. 


PSEUDO-HYPERTROPIIIC   PARALYSIS.  637 

discrimination  of  cases  of  pseuclo-hypertrophic  paralysis  from  those  of 
progressive  muscular  atrophy  occurring  in  infants,  infantile  paralysis, 
and  the  tardy  development  of  the  courdinative  and  motor  functions  in 
young  children.  But  it  appears  to  me  that  very  slight  inquiry  and 
examination  will  suffice  to  make  errors  in  regard  to  any  of  these  con- 
ditions almost  impossible  on  the  part  of  any  one  capable  of  distinguish- 
ing one  disease  from  another. 

Prognosis. — The  prognosis  is  unfavorable.  Two  cases  of  recovery 
are  related  by  Duchenne,  and  other  observers  have  reported  improve- 
ments, but  the  tendency  is  to  death,  though  life  may  be  prolonged 
many  years  notwithstanding  the  gradual  advance  of  the  disease.  And 
yet  the  fatal  result  is  rarely  directly  due  to  the  disease  itself.  Some 
intercurrent  affection  ensues,  and  the  vital  power,  being  enfeebled, 
cannot  resist  effectually  the  new  disorder.  Thus  death  occurred  in 
my  first  case  by  pneumonia  ;  and  of  thirteen  cases  referred  to  by 
Poore,  in  which  the  termination  is  given,  not  one  died  directly  of  the 
disease. 

Morbid  Anatomy  and  Pathology.— When  the  study  of  this  affection 
was  in  its  infancy,  certain  changes  discovered  in  the  spinal  cord,  and 
particularly  in  the  cells  of  the  anterior  horns,  were  regarded  as  the 
primary  lesions  of  this  disease.  Reports  of  cases  in  which  autopsies 
were  obtained  by  Barth,1  Midler,2  and  Clark,3  in  earlier  years,  and  even 
in  later  years  by  Gjbncy  and  Amidor.,4  seemed  to  confirm  this  view  of 
the  case  ;  but  since  then  more  careful  investigation  of  the  subject  by 
Middleton  5  and  Schultzc,8  and  still  more  recently  by  Sachs,7  shows 
almost  conclusively  that  the  primary  pathological  change  occurs  in  the 
muscles,  and  that  in  the  majority  of  instances  the  spinal  cord  is  free 
from  any  semblance  of  disease.  Sachs,8  in  his  interesting  paper  on 
i his  subject,  collected  seventeen  cases  of  this  disease,  in  all  of  which 
scientific  examinations  of  the  cord  were  properly  conducted.  In  eleven 
of  these  "ill"  spinal  cord  and  anterior  nerve-roots  were  found  abso- 
lutely normal"  ;  in  the  other  six  cases  "the  changes  that  were  found 
could  not  be  held  responsible  for  the  changes  in  the  muscles." 

Maudford"  contributes  another  case,  the  study  of  which  confirms 

1  "Beitrage  zur  Kenntniss  dcr  atrophia  musculorum  lipomatosa,"  Archiv  <1> r  //</'/- 
kunde,  Leipzig,  1871,  p.  120. 

1  "BeitrSge  zur  path.  Anal  and  Physiol,  des  menschlichen  Riickenmarks,  Heft  ii., 
Leipzig,  ls7i>. 

*  Journal  of  Mental  Sciences,  April,  1870,  p.  II. 

4  'I  i  oftJu  American  Neurological  Association,  1SS6. 

•  Qlax'/oi"  Mnli.-iil  Jonr/Kt/,   Iss  1,  \„.  !>•_',  p.  81. 

'■  "  Deber  den  mit  Uypertrophio  rerbundenen  progressives   Muskelschwund,"  v 
baden,  1 886. 

1  Transactions  of  th<  Ann  riant  Xruro'ni/irn!  .tss'icititioni  1880. 

8  Ibid, 

9  Transactions  of  iht  Pathological  Society,  London,  1SS8-89,  xl.,  p.  84 


638  DISEASES   OF   THE   SPINAL   CORD. 

the  view,  already  expressed,  of  the  myotic  origin  of  the  disease.  The 
autopsy  demonstrated  the  unusual  extent  to  which  the  disease  had 
advanced.  In  addition  to  the  atrophy  of  the  extremities,  the  muscles 
of  the  trunk  were  greatly  affected.  The  pectoral  muscles  had  disap- 
peared entirely,  and  the  heart  and  diaphragm  were  both  degenerated. 
Sections  of  the  cord  at  all  levels  showed  that  the  cells  in  the  anterior 
horn  were  mainly  in  good  condition,  and  seemed  to  be  in  their  usual 
numbers.  In  most  sections  cells  could  be  seen  here  and  there  pig- 
mented, or  that  did  not  stain  well,  or  that  had  lost  their  processes,  or 
in  some  way  appeared  degenerated.  Such  cells  were,  however,  on  the 
whole  very  few,  and  were  not,  in  the  author's  opinion,  sufficiently 
degenerated  to  account  for  such  universal  and  extensive  muscular 
degeneration.  In  the  upper  lumbar  enlargement  an  area  of  softening 
was  discovered  situated  in  the  gray  substance  of  one  lateral  half,  inter- 
mediate between  the  anterior  and  posterior  horns.  It  seemed  to  be 
the  result  of  a  comparatively  recent  haemorrhage. 

It  cannot  be  entertained  for  a  moment  that  the  area  of  softening 
was  in  any  manner  related  to  the  symptoms  of  pseudo-hypertrophic 
paralysis.  Its  situation  in  one  half  of  the  cord  and  in  the  lumbar 
region,  and  the  fact  that  it  did  not  involve  any  of  the  multipolar  cells, 
precludes  the  possibility  of  its  affecting  muscles,  especially  those  sup- 
plied from  regions  of  the  cord  above  the  seat  of  the  softening.  The 
slightly  degenerated  appearance  of  some  of  the  cells  in  the  anterior 
horn  probably  ensued  because  they  were  useless,  the  muscular  fibres 
which  they  supplied  having  disappeared. 

The  nerve-roots  were  healthy. 

Thus  it  would  seem  that  the  weight  of  evidence  tends  to  prove 
that  pseudo-hypertrophic  paralysis  is  not  a  disease  of  the  central 
nervous  system.  The  majority  of  observers  agree  upon  the  morbid 
changes  which  occur  in  the  muscles.  In  the  first  stage  there  may  be 
— as  Pepper  has  shown,  as  my  second  case  likewise  exhibits,  and  as 
occurred  in  Therese's1  case — atrophy  of  the  muscular  fibres  instead  of 
hypertrophy.  A  microscopical  examination  shows  the  transverse  striae 
to  be  in  process  of  disappearing,  and  in  some  of  the  fibrillar  to  have 
altogether  gone. 

The  connective  tissue  already  shows  a  tendency  to  proliferation, 
but  there  is  as  yet  no  trace  of  that  fatty  degeneration  and  deposit 
which  afterward  becomes  the  most  striking  patho-anatomical  feature 
of  the  disease.  In  the  case  which  I  have  detailed,  a  portion  of  the 
primarily-atrophied  left  rectus  femoris  muscle  was  removed  by  Du- 
chenne's  trocar,  and,  examined  with  a  fourth-inch  objective,  presented 
the  appearance  above  described.  In  Pepper's  case  not  a  single  fibril 
of  the  deltoid  muscle  which  he  examined  exhibited  evidence  of  fatty 
degeneration,  though  the  connective  tissue  was  very  greatly  in  excess 
1  France  Med.,  Taris,  1889,  i.,  p.  814. 


PSEUDO-nYPERTROPHIC   PARALYSIS.  639 

of  the  normal  proportion,  and  in  places  there  were  small  collections  of 
minute  fat-globules  or  refracting  granules. 

But  in  the  form  in  which  hypertrophy  is  a  prominent  feature  there 
may  or  may  not  be  hypertrophy  of  the  muscular  fibres.  Virchow 
claims  that  hypertrophy  of  the  muscular  fibres  is  pathognomonic  of  the 
disease,  but  in  JacobyV  case  there  was  a  distinct  diminution  in  the 
number  of  muscular  fibres,  some  of  which  were  small  and  some  were 
normal,  but  none  of  them  were  hypertrophied.  Middleton2  noted 
variations  in  thickness  of  the  muscular  fibres.  In  some  instances  they 
appeared  hypertrophied,  in  others  they  did  not.  All  observers  agree 
that  there  is  a  notably-increased  development  of  the  connective  tissue. 
with  fatty  infiltration,  and  fatty  degeneration  of  the  muscular  fibres. 

As  the  process  advances,  the  fibrilla3  in  great  part  disappear,  fat 
and  connective  tissue  crowding  them  out,  as  it  were,  and  eventually 
even  this  latter  is  in  a  great  measure  replaced  by  fat-vesicles.  The 
muscle  is  now  at  its  most  advanced  stage  of  hypertrophy.  But  the 
process  is  not  yet  complete,  for  a  stage  of  secondary  atrophy  begins, 
the  fat  is  absorbed,  and  finally  nothing  is  left  but  a  few  degenerated 
muscular  fibrillar  and  a  mass  of  connective  tissue. 

There  is  thus  in  the  first  place  simply  a  change  in  the  muscular 
fibrillaB  characterized  by  a  disappearance  of  the  transverse  striae.  This 
is  probably  the  first  stage  of  the  fatty  degeneration,  which  is  afterward 
manifested  unmistakably.  At  the  same  time  the  connective  tissue 
between  the  bundles  of  fibrillaB  and  the  fibrillae  themselves  is  increased 
in  amount.  Then  the  disintegration  of  the  muscular  fibrillar  becomes 
more  evident,  the  connective  tissue  is  still  more  increased,  and  fat- 
vesicles  make  their  appearance  between  the  fibrillse  and  the  bundles  of 
fibres.  Finally,  the  muscular  tissue  mostly  disappears,  the  fat  is  ab- 
BOrbed,  and  connective  tissue,  with  perhaps  a  few  fibril  hv,  in  a  more  or 
less  advanced  stage  of  degeneration,  is  all  that  remains. 

It  is  therefore  evident,  from  what  has  been  sai<l,lhat  pseudo-hyper- 
trophic  paralysis  is  primarily  a  muscular  dystrophy,  beginning  as  an 
inflammation  of  the  muscular  tissue  and  connective  tissue,  and  ending 
with  a  more  or  less  complete  degeneration. 

Treatment. — Duchenne,  as  we  have  seen,  succeeded  in  curing  two 
oases  in  t  heir  inoipiency,  with  tin  faradaic  current.    Authors  are  agreed 

that,  if  anything  is  likely  to  prove  successful,  it  is  electricity  in  some 
one  of  its  forms,  and  all  cases  have  been  treated  with  this  agent.  Thus 
far,  however,  not  only  is  there  no  record  of  another  cure,  hut  there  is 
scarcely  the  mention  of  even  slighl  improvement.  The  disease  has 
gone  on  slowly  hut  certainly  in  its  progress,  unchecked  by  therapeuti- 
cal measures. 

Still  we  are   not,  on  that  account,  to  despair.      I  would    recommend 

faradization  and  galvanization  of  the  affected  muscles,  the  application 
1  Journal  of  Nervous  and  Mental  Diseases,  1887.  -  <>/>.  cit. 


640  DISEASES   OF   THE   SPINAL   CORD. 

of  heat,  kneading  the  muscles,  massage,  and  rest.  Of  these  remedies 
I  consider  faradization  the  most  important.  It  should  be  applied  once 
or  twice  a  day  to  all  the  implicated  muscles. 

Internally,  strychnia,  iron,  and  phosphorus  may  be  used,  and  bene- 
fit may  be  derived  from  their  tonic  virtues. 


This  concludes  what  I  have  to  say  relative  to  the  diseases  of  the 
spinal  cord.  I  have  endeavored  to  make  the  subject  as  plain  as  possi- 
ble, but,  in  the  study  of  a  class  of  diseases  still  to  a  great  extent  ob- 
scure in  their  medical  relations,  there  must  necessarily  be  defects  in 
the  description. 

In  order  to  a  better  understanding  of  the  normal  and  morbid  anat- 
omy of  the  cord,  as  established  by  the  most  recent  investigations,  I 
have  enlarged  and  modified  from  Flechsig  and  from  Gowers  a  diagram 
of  a  transverse  section,  which  will  be  found  to  give,  on  examination, 
very  exact  information.  In  it  are  clearly  indicated  the  several  divisions 
of  the  cord  with  the  study  of  which  we  have  been  engaged. 


A.  Anterior  Median  Fissure. 

B.  Posterior  Median  Fissure. 

C.  Intermediate  Fissure. 
I).  Anterior  Gray  <  !ornu. 
E,  Posterior  Gray  Cornu. 

P.  Gray  Commissure,  with  Central  Canal. 

(i.  Anterior  Pyramidal  Tract,  <>r  Uncrossed  Pyramidal  Tract,  or  Column  of  Tflrck. 

I.  Anterior  Root  -Zones. 

B    Lateral  Pyramidal  Tract,  or  Crossed  Pyramidal  Tract 

L.  Direcl  <  'erebellar  Tract. 

M.  Posterior  External  Column,  or  Column  of  Burdach. 

N.  Posterior  Median  Column,  or  Column  <>f  Goll. 

P.  Antero-Lateral  Ascending  Tract,  or  Column  ofGowers, 


SECTION    III. 
CEKEBKO-SPOTAL   DISEASES. 


CHAPTER    I 

HYDROPHOBIA. 


Although  there  are  objections  to  the  name  employed  to  designate 
the  terrible  disease  I  now  propose  to  consider,  the  same  is  true  of  all 
other  terms  which  have  been  applied  to  it,  and  the  present  has  the  ad- 
vantage of  being  well  known.  So  long  as  we  are  obliged,  through  ig- 
norance of  pathology  and  morbid  anatomy,  to  use  a  nomenclature  based 
on  symptoms,  we  must  expect  to  be  inexact.  The  name  hydrophobia 
is  as  old  as  Galen,  and  still  retains  its  preeminence,  notwithstanding 
the  fact  that  the  symptom  on  which  it  is  based  is  sometimes  absent. 

Symptoms. — Beginning  with  the  reception  of  the  injury  by  which 
the  body  has  been  inoculated,  we  find  that  it  heals  in  the  ordinary  way, 
and  that  there  are  no  immediate  signs  of  infection.  At  a  period  which 
varies  greatly  in  different  cases,  pain  or  a  sensation  of  uneasiness  is 
usually  experienced  at  the  seat  of  the  wound.  This,  however,  is  rarely 
of  such  intensity  as  to  cause  suffering,  and  probably  would  generally 
be  overlooked  or  disregarded  but  for  the  apprehension  which  the  pa- 
tient has,  and  which  directs  his  attention  to  every  sensation  which  can 
be  attributed  to  the  wound.  But  there  may  be  absolutely  no  pain  or 
uneasiness  other  than  such  as  are  met  with  in  all  wounds  till  the  phe- 
nomena of  the  affection  are  manifested.  The  period  between  the  re- 
ception of  the  injury  and  the  beginning  of  the  symptoms  of  hydropho- 
bic is  known  as  the  stage  of  incubation. 

The  duration  of  this  stage  is  variable.  It  is  rarely  shorter  than  a 
month,  and  probably  never  longer  than  two  years.  Instances  are  on 
record,  however,  in  which  the  disease  has  been  developed  within  ten 
days,  and  others,  about  whioh,  however,  there  is  much  doubt,  in  which 
the  latent  period  has  reached  to  ten  years  and  longer.  The  vast  ma- 
VI 


642  CEREBRO-SPINAL  DISEASES. 

jority  of  cases  occur  within  seven  months  after  the  reception  of  the 
wound.  In  six  cases  which  have  been  under  my  observation,  the  period 
of  incubation  varied  from  about  twenty-five  days  to  four  months  and  a 
half. 

Dr.  John  Johnston,1  however,  refers  to  an  opinion  that  in  hot  coun- 
tries the  disease  has  appeared  in  four  or  five  days  after  the  bite,  and,  on 
the  margin  of  the  page  on  which  this  statement  is  made,  Dr.  Hosack, 
to  whom  the  book  formerly  belonged,  has  written  a  note,  in  which  he 
states  that  it  ensued  in  a  child  in  New  York  five  days  after  the  bite 
was  inflicted. 

During  this  period  of  incubation  there  are  not  often  any  indications 
of  what  is  going  to  take  place  except  in  those  cases  in  which  there  are 
abnormal  sensations  in  the  cicatrix  or  its  neighborhood.  Sometimes 
there  are  depression  of  spirits,  anxiety,  and  derangement  of  the  diges- 
tive functions,  but  these  symptoms  may  fairly  be  attributed  to  the  pe- 
culiar circumstances  of  the  case,  aside  from  any  toxic  influence  due  to 
infection. 

The  first  symptoms  which  appear  are  often  directly  connected  with 
the  cicatrix,  which,  if  it  has  previously  been  free  from  abnormal  appear- 
ances and  sensations,  now  becomes  subject  to  both.  But  there  is  no 
constancy  even  in  these  phenomena.  They  were  altogether  absent  in 
one  of  my  cases,  and  very  slightly  manifested  in  one  other,  if  they  were 
present  at  all.  In  this  case,  which  I  saw  in  consultation  with  Dr.  S.  G. 
Cook,"  of  this  city,  the  patient,  after  other  symptoms  had  appeared,  oc- 
casionally clutched  the  place  where  he  had  been  bitten,  but  denied,  on 
being  asked,  that  there  was  any  pain  at  the  spot. 

But,  though  there  may  be  no  symptoms  of  swelling,  redness,  or  pain 
about  the  cicatrix,  there  are  abnormal  sensations  in  the  nerves  which 
radiate  from  it.  Thus,  if  the  injury  has  been  in  the  leg,  pains  are  felt 
along  the  courses  of  the  sciatic  and  crural  nerves  ;  if  in  the  hand,  simi- 
lar sensations  are  experienced  in  the  radial,  ulnar,  median,  and  other 
nerves  of  the  upper  extremity.  Occasionally  the  pain  is  felt  in  the  epi- 
gastric region,  and  in  any  situation  is  ordinarily  accompanied  by  head- 
ache. At  about  the  same  time  the  respiration  becomes  sighing  and 
irregular,  there  is  a  feeling  of  oppression  or  constriction  in  the  chest, 
the  pulse  loses  its  force  and  uniformity,  and  there  is  an  indefinable 
sense  of  anxiety.  The  sleep  is  scarcely  ever  natural.  Either  there  is 
insomnia  or  drowsiness,  and  sleep,  when  obtained,  is  disturbed  by  fright- 
ful dreams,  and  is  unrefreshing.  The  bowels  are  constipated,  the  skin 
is  dry,  and  there  are  alternate  chills  and  flushes  of  heat.  The  duration 
of  this  stage  is  from  two  to  four  days. 

And  then  the  period  of  full  development  begins  ;  characterized,  at 
first,  by  an  increase  in  the  symptoms  just  mentioned,  and  subsequently 

1  "Cases  of  Lyssa,  with  Remarks,"  p.  5,  in  "Medical  Essays,"  printed  1*795  to  1805. 

2  "  A  Case  of  Hydrophobia,"  Journal  of  Psychological  Medicine,  January,  1870,  p.  80. 


HYDROPHOBIA.  643 

by  the  appearance  of  others  not  previously  present.  A  peculiar  sense 
of  uneasiness  is  felt  at  the  epigastrium,  and  a  pain  and  constriction  of 
the  throat,  which  add  greatly  to  the  distress.  The  tongue  becomes 
stiff  and  painful,  and  articulation  is  thereby  rendered  indistinct  ;  the 
respiration  increases  in  irregularity,  and  becomes  noisy  and  oppressed  ; 
the  rigidity  of  the  muscles  of  the  throat  prevents  or  impedes  degluti- 
tion, and  the  patient  dreads  attempting  to  swallow,  from  the  experience 
he  soon  acquires  that  his  efforts  in  this  direction  are  attended  with  pain 
and  spasm,  which  greatly  increase  his  sufferings.  Sometimes  the  con- 
vulsion of  the  pharyngeal  muscles  is  so  great  that  substances  are  thrown 
with  great  force  out  of  the  mouth.  This  was  the  case  in  three  of  the 
instances  I  witnessed.  At  the  same  time  the  spasm  extends  to  other 
parts  of  the  body,  and  occasionally  becomes  general.  It  is  accompanied 
by  pain  in  the  epigastrium,  and  sometimes  in  the  spine.  Solids  are 
swallowed  with  much  more  ease  than  liquids.  Indeed,  so  great  is  the 
difference  that  the  patient  cannot  even  entertain  the  idea  of  swallow- 
ing any  fluid,  without  being  thrown  into  spasms.  The  sound  of  water 
splashing  or  trickling,  the  sight  of  it,  the  thought  of  it,  and  even  an 
impression  remotely  connected  with  water,  such  as  that  produced  by 
the  reflection  of  rays  of  sunlight  on  the  face  by  a  mirror,  will  bring  on 
a  paroxysm  of  convulsions.  With  the  spasm  there  are  sobbings,  trem- 
bling, and  then  a  condition  of  exhaustion,  during  which  the  patient  is 
bathed  in  perspiration. 

The  following  day  the  phenomena  are  still  more  strongly  marked. 
The  mouth  is  dry  and  parched,  and  yet  the  patient  dare  not  attempt 
to  quench  his  thirst  ;  vomiting  ensues,  the  pulse  becomes  rapid  and 
small,  the  pain  in  the  pit  of  the  stomach  still  increases,  the  headache  is 
intense,  and  the  countenance  expresses  terror,  anxiety,  and  suffering. 
The  pain  in  the  spine  augments  and  extends  to  the  muscles  of  the  neck 
and  abdomen.  The  secretions  of  the  mouth  are  altered,  and  the  saliva 
is  mixed  with  a  frothy,  tenacious  mucus,  which  the  patient  is  constant- 
ly attempting  to  eject,  but  which  collects  as  fast  as  he  can  spit  it  out. 
The  mouth  and  fauces  are  dry  and  painful,  articulation  is  almost  im- 
possible, and  every  attempt  to  relieve  the  distress  by  a  few  drops  of 
water  induces  a  return  of  the  spasms  and  convulsions.  Finally,  every 
reflex  excitation  reaches  the  muscles  of  the  throat  ;  the  contact  of  the 
bedclothes,  the  jarring  of  the  bed  by  persons  walking  in  the  room,  the 
rustling  of  window-curtains — any  thing  capable  of  acting  on  the  hear- 
ing, the  eyesight,  or  the  touch,  may  cause  the  spasms. 

As  the  disease  advances,  all  the  symptoms  increase  in  violenoe,  and 
still  others  make  their  appearance.  The  urine  and  fieces  are  often 
passed  involuntarily,  the  skin  becomes  exquisitely  sensitive,  the  body 
is  in  a  constant  state  of  agitation  and  tremor,  alternating  with  spasms, 
and  the  tough,  stringy,  tenacious  mucus  collects  in  the  throat  and  im- 
pedes  respirationt 


644  CEREBRO-SPINAL  DISEASES. 

Thus  far  the  mental  symptoms  have  scarcely  been  considered,  but 
they  are  present  almost  from  the  first.  Indeed,  they  may  be  among  the 
very  first  indications  of  disorder.  They  consist  of  emotional  disturb- 
ances of  various  kinds,  and  sometimes  radical  changes  of  character  and 
disposition. 

It  has  been  alleged  by  some  authors  that  the  dreams,  at  a  very  early 
period  after  inoculation,  are  connected  with  the  animal  giving  the 
the  wound.  I  have  never  met  with  this  symptom,  but  in  the  case  pre- 
viously cited,  and  which  I  saw  twice  in  consultation,  a  circumstance 
still  more  remarkable  is  related  by  Dr.  Cook.  The  patient,  a  child 
three  years  old,  was  bitten  by  a  bitch  in  .heat  on  or  about  August  20, 
1870.  On  November  15th  the  mother  noticed  that  he  slept  badly  ;  on 
the  16th,  among  other  manifestations,  he  "  was  cranky  all  day."  On 
the  17th  he  was  seen  by  Dr.  Cook.1 

"  On  entering  the  room,"  says  the  doctor,  in  his  report  of  the  case, 
"  and  seeing  several  children,  and  not  noticing  any  thing  wrong  with 
any  of  them,  I  very  naturally  inquired  which  was  the  patient.  I  was 
pointed  to  a  little  boy  sitting  at  a  table  in  a  high  chair.  On  approach- 
ing him,  he  turned  his  face  toward  me,  revealing  the  most  peculiar-look- 
ing eyes  I  have  ever  seen.  They  were  not  like  those  seen  in  persons 
suffering  from  delirium  in  prolonged  fevers,  nor  yet  like  those  we  see 
in  the  second  stage  of  cerebral  meningitis,  although  somewhat  resem- 
bling both  of  these  conditions,  but  more  like  the  eyes  of  a  person  in  a 
fit  of  violent  anger,  slightly  combined  with  a  feeling  of  fear. 

"  When  I  reached  out  my  hand  to  touch  his,  he  shrank  from  me  as 
from  a  blow,  at  the  same  time  making  a  desperate  effort  to  catch  his 
breath,  precisely  as  a  naked  person  might  if  a  pail  of  cold  water  was 
unexpectedly  poured  over  him.  This  I  understood  to  be  a  laryngeal 
spasm.  It  was  very  brief,  lasting  but  the  fraction  of  a  minute,  prob- 
ably not  more  than  ten  seconds.  I  took  a  seat  a  little  distance  from 
him,  where  I  could  see  his  every  motion,  and  regarded  him  attentively 
for  a  long  time. 

"  He  seemed  an  unusually  intelligent  child,  for  one  of  his  age,  speak- 
ing very  distinctly  with  a  clear,  ringing  voice,  which  his  parents  in- 
formed me  was  a  little  unnatural,  as  it  'seemed  strained.'  He  had  at 
times  a  disposition  to  stammer,  which  was  also  unnatural.  For  one 
hour  after  my  observation  commenced,  he  talked  almost  incessantly  of 
dogs,  and  repeated  very  few  sentences  a  second  time.  He  seemed 
familiar  with  all  the  most  common  breeds,  relating  some  anecdote 
of  the  bull-dog,  the  mastiff,  the  bird-dog,  the  spaniel,  the  coach-dog, 
and  the  poodle. 

"  Connected  with  all  his  naratives  was  a  tragic  or  gloomy  termina- 
tion. The  mastiff,  after  carrying  him  an  incredible  distance  about  the 
city,  finally  disappeared  through  a  bottomless  hole  in  the  street,  he  only 

1  Op.  tii.t  p.  81. 


HYDROPHOBIA.  645 

escaping  a  similar  fate  by  suddenly  dismounting.  The  bull-dog,  after 
bringing  for  his  admiration  and  pleasure  a  great  variety  of  puppies,  sud- 
denly turned  cannibal,  and  swallowed  the  whole  lot.  The  spaniel,  after 
having  been  his  playmate  for  a  very  long  time,  finally  took  it  into  his 
head  one  day  to  get  on  to  a  coffin  that  was  being  carried  through  the 
streets,  and  ride  away  to  reappear  no  more." 

There  were  no  other  evidences  of  disordered  mental  action  in  this 
child,  and  he  died,  perfectly  conscious  to  the  last. 

Usually,  however,  this  is  not  the  case,  and  various  morbid  desires 
are  entertained  by  the  patient.  Thus,  in  a  case  which  I  saw  in  this 
city  in  1865,  there  was  an  impulse  to  strike  those  near,  and  an  intense 
dislike  of  certain  persons  who  had  always  been  intimate  friends  of  the 
patient.  In  both  the  other  cases  there  were  paroxysms  of  previous 
delirium,  during  which  the  sufferers  bit  and  struck  at  all  within  their 
reach,  and  of  which  hallucinations  and  delusions  constituted  marked 
features.  In  the  case  of  the  boy  just  cited,  the  stories  of  dogs  which  he 
related  were  evidently  delusions  which  he  accepted  as  realities. 

The  temperature  is  always  elevated  from  the  very  beginning  of  the 
disease.  It  is  rarely  below  105°  Fahr.,  and  may  rise  as  high  as  110° 
during  the  height  of  a  paroxysm  or  immediately  after  its  cessation. 

Death  usually  takes  place  on  the  third  day  after  the  accession  of  the 
symptoms  indicating  the  full  development  of  the  disease.  The  chief  of 
these  is  laryngeal  spasm.  A  fatal  termination  is  rarely  delayed  till 
after  the  third  day,  though  cases  are  not  uncommon  in  which  it  has  en- 
sued on  the  first  or  second  day.  In  all  the  cases,  except  two,  which  have 
been  under  my  observation,  the  third  was  the  fatal  day.  In  Dr.  Cook's 
the  disease  may  be  considered  as  having  been  fairly  developed  on  the 
17th  of  November,  the  first  day  in  which  any  spasm  of  the  throat  was 
witnessed.     Death  resulted  on  the  evening  of  the  18th. 

In  June,  1874,  I  attended,  in  consultation  with  Dr.  Alexander 
Hadden,  my  sixth  case  of  hydrophobia.  The  patient,  a  man  about 
twenty-five  years  of  age,  had  been  bitten  about  three  weeks  before  by  a 
dog  not  clearly  identified.  When  Dr.  Hadden  first  saw  him  on  the  24th 
of  June,  at  8.30  p.  m.,  the  man  was  in  bed,  complaining  of  nervousness, 
soreness  in  his  neck  and  throat,  and  a  strange  feeling  of  tightness 
around  the  chest.  His  countenance  was  anxious,  his  pupils  were  di- 
lated, and  his  general  appearance  was  that  of  a  person  facing  some  im- 
pending danger,  and  not  in  extreme  pain.  Be  said  his  throat  was 
ami  thai  he  could  not  swallow  any  thing,  not  even  wafer.  Examination 
showed  that  there  was  no  congestion  or  inflammation  of  his  throat. 
His  |  piration,  and  temporal  ore,  were  normal,  except  ing  that  he 

occasionally  sighed.  There  was  als<>  a  little  disposition  to  hack  and 
spit.  He  complained  of  thirst,  bul  Baid  he  knew  li<-  oould  \\><\  drink,  for 
the  very  sight  of  water  made  him  Bhudder.  He  was  told  t<>  try,  and 
some  water  was  brought,  but  the  sight  of  it  caused  a  violent  sj>;i<m.    1 1  *> 


646  CEREBRO-SPIXAL   DISEASES. 

threw  himself  around  in  the  bed  backward  and  forward,  and  ordered  the 
water  to  be  taken  away.  He  immediately  afterward  called  for  the 
goblet,  said  he  was  thirsty  and  must  drink,  seized  it,  and  with  a  violent 
effort  succeeded  in  taking  a  single  swallow,  which  was  followed  by  a 
severe  convulsive  shudder  and  contraction  of  the  muscles  of  the  neck 
and  chest. 

Dr.  Hadden,  recognizing  the  symptoms  of  hydrophobia,  asked  if  he 
had  been  recently  injured  by  any  animal.  At  first  he  replied  in  the 
negative,  but  on  the  doctor's  saying,  "  Not  by  a  dog  ? "  he  answered, 
"  Only  slightly  on  the  knuckle  of  the  right  hand  by  a  little  black  dog 
belonging  to  a  baker  around  the  corner,  on  the  avenue."  He  further 
stated  that  there  was  nothing  the  matter  with  the  dog,  for  he  had  seen 
it  afterward,  and  only  about  a  week  since  it  had  been  taken  to  the 
pound  and  the  bite  was  inflicted  three  or  four  weeks  before. 

For  two  days  previously  he  had  felt  badly,  was  thirsty,  and  had 
drunk  a  good  deal  of  water;  and  the  evening  before  had  gone  out,  but 
soon  returned,  saying  he  felt  chilly.  While  taking  a  cup  of  tea  at  6  p.  m. 
that  day  (the  23d),  he  had  experienced  the  first  difficulty  in  swallowing. 
Shortly  afterward,  while  going  to  the  kitchen,  a  cool  draught  of  air 
blew  on  him  and  caused  him  to  stagger  so  that  he  nearly  fell. 

The  next  morning  Dr.  Hadden  saw  him  with  Dr.  Leavitt. 

"We  found  him  in  a  frightful  state  of  excitement;  had  broken 
down  the  bed,  and  was  struggling  with  his  attendants  to  get  at  liberty. 
He  was  shouting  and  crying  out  to  them  to  let  him  go,  and  called  for 
wrater,  which,  when  brought,  he  could  not  drink.  His  mind  was  clear, 
and  he  knew  all  those  around  him;  was  spitting  a  viscid  saliva,  and  was 
careful  not  to  spit  on  any  one,  not  even  on  his  clothes.  It  was  so 
abundant  that  his  attendants  were  obliged  to  wipe  it  from  his  lips.  Dr. 
Leavitt  and  myself,  after  viewing  the  case  in  all  its  aspects,  concluded 
to  inject  in  the  tissue  of  the  leg  one-half  a  grain  of  morphine  and  one 
sixty-fourth  of  a  grain  of  atropine  in  solution,  which  was  done  at  3 
A.  M.  by  Dr.  Leavitt.  We  carefully  watched  the  effect  till  3.30  A.  m., 
when  his  violence  having  in  no  way  abated,  another  injection  was  given 
in  the  same  part,  of  three-eighths  of  a  grain  of  morphine  and  one-eighth 
of  a  grain  of  atropine,  which  in  some  degree  produced  the  character- 
istic effect  of  morphine,  and  very  clearly  the  appearances  of  the  atro- 
pine; for,  notwithstanding  he  was  struggling  violently,  the  saliva,  which 
had  been  very  troublesome,  was  completely  dried  up,  so  much  so  that 
the  patient  himself  remarked  that  he  was  very  thirsty,  and  his  mouth 
felt  as  if  he  had  been  chewing  a  brick.  Fifteen  drops  of  chloroform 
were  then  injected,  with  no  effects  whatever,  unless  to  weaken  his  al- 
ready weak  and  frequent  pulse.  At  4.15  A.  M.,  three-eighths  of  a  grain 
of  morphine  were  again  introduced  under  the  skin,  without  atropine. 
This  quieted  the  patient  so  that  he  was  easily  restrained,  and  he  re- 
mained in  this  condition  from  4.30  A.  m.  till  10  A.  m.,  when  the  effects 


HYDROPHOBIA.  647 

had  so  far  passed  off  that  the  attendants  were  alarmed  at  his  violence, 
and  the  abundance  of  saliva  he  was  spitting  from  his  mouth.  Dr.  Wil- 
liam A.  Hammond  saw  him  with  me  at  this  time.  He  supported  the 
diagnosis  and  thought  well  of  the  treatment;  he  saw  that  it  subdued  vio- 
lence and  suppressed  the  flow  of  saliva — the  two  most  important  feat- 
ures of  this  hopeless  disease.  At  10.15  a.  m.,  by  his  order,  three- 
eighths  of  a  grain  of  morphia  in  solution  were  injected  into  the  tissue 
of  the  thigh,  which  served  to  temper  down  the  increasing  violence  of 
the  spasms,  but  did  not  stop  the  flow  of  saliva.  I  accordingly,  at  10.45 
A.  5r.,  injected  three-eighths  of  a  grain  of  morphia  and  one-fortieth  of  a 
grain  of  atropia,  which  had  the  desired  effect  of  producing  the  quieting 
effect  of  the  morphia  as  well  as  the  specific  effect  cf  the  atropia  on  the 
salivary  glands.  The  poisonous  effects  of  the  morphia  and  atropia  were 
at  no  time  apparent.  He  died  at  4.15  P.  M.,  June  26, 1874,  about  twenty- 
four  hours  after  the  first  spasm."  ' 

As  stated  by  Dr.  Hadden,  I  was  called  to  see  the  patient  at  about 
ten  o'clock  on  the  morning  of  June  26th.  "When  I  went  into  the  room 
he  was  lying  upon  the  floor  pinioned,  to  a  certain  extent,  and  surround- 
ed with  pillows  to  prevent  him  injuring  himself.  He  was  then  spitting 
continually  ;  in  fact,  every  expiration  was  accompanied  by  an  effort  to 
spit  out  the  thick,  tenacious  mucus  so  characteristic  of  hydrophobia. 
His  pupils  were  largely  dilated,  but,  as  Dr.  Hadden  stated,  not  more 
so  than  before  the  atropia  was  given.  He  was  able  to  converse  with 
tolerable  fluency,  and,  when  1  put  two  or  three  questions  to  him,  he  an- 
swered, but  not  very  directly.  So  far  as  I  could  make  out,  both  from 
his  answers  and  appearance,  he  was  not  suffering  from  acute  pain. 
There  was  a  good  deal  of  movement  of  his  limbs,  not  apparently  spas- 
modic, for  there  seemed  to  be  the  element  of  volition  in  the  actions  he 
made  with  his  arms  and  legs.  He  could  not  swallow  fluids,  and  even  a 
piece  of  ice  given  to  him  was  ejected  with  force  from  his  throat.  His 
pulse  was  too  rapid  to  be  counted,  and  his  respiration  was  hurried  and 
irregular. 

I  fully  concurred  in  the  suggestion  to  give  him  morphia  for  the  pur- 
pose of  moderating  the  intensity  of  his  symptoms.  A  hypodermic  in- 
jection was  administered,  and  a  sedative  effect  was  produced.  After  I 
left,  his  paroxysms  returned  with  great  violence,  and  he  died  that  after- 
noon. 

Generally  death  occurs  during  a  spasm.  This  was  the  result  in  four 
of  the  six  <;ises  I  have  witnessed.  In  the  others  the  patients  died 
quietly,  a  consequence  probably  of  the  sedative  medioines administered. 
When  death  takes  place  during  the  former  condition  it  is  probably  due 
to  apncea  ;  in  the  latter,  to  exhaustion.     Ju  all  cases  the  powers  of  life, 

1  "Report  of  :i  Case  of  Hydrophobia,"  by  Alexander  Hadden,  M.  i>.,  "  Prooeedinga 
nf  the  New  York  Neurological  Booiety,"  /'  and Mtdico-Ltgal  Journal^  Sij>- 

tembnr,  1871,  p.  lt'.ti. 


648  CEREBRO-SPINAL  DISEASES. 

from  the  violent  convulsions,  the  loss  of  sleep,  and  the  deprivation  of 
food,  are  drained  away  to  their  utmost. 

The  most  recent  case  of  hydrophobia  coming  under  my  observation 
was  that  of  a  gentleman  whom  I  saw  at  Haverstraw,  New  York,  in 
consultation  with  Dr.  W.  B.  Bailey,  of  that  place,  on  May  25,  1887. 
The  patient  was  bitten  on  the  thumb  by  a  small  pet  dog  which  had 
been  bitten  some  time  before  by  a  strange  cur.  On  a  previous  occasion 
the  patient  had  found  a  bone  lodged  in  the  dog's  throat,  and,  from  the 
symptoms  exhibited,  thinking  that  something  of  this  kind  ailed  the 
dog  again,  the  owner  put  his  hand  down  the  animal's  throat,  and  the 
thumb,  coming  in  contact  with  one  of  the  sharp  teeth,  was  slightly  cut. 
A  short  time  afterward  the  dog  died.  Little  was  thought  of  the  wound 
at  the  time  ;  but  in  a  few  days  afterward  the  thumb  became  painful 
and  began  to  swell,  and  Dr.  Bailey  cauterized  the  wound.  The  swell- 
ing gradually  advanced  up  the  arm,  and  became' so  painful  that  he  was 
unable  to  sleep.  All  this  subsided,  however,  until  almost  exactly  a 
month  subsequent  to  the  infliction  of  the  wound  the  first  manifesta- 
tions of  hydrophobia  made  their  appearance.  I  saw  him  on  the  fourth 
day,  about  six  o'clock  in  the  evening,  and  he  was  then  in  bed  sleeping 
quietly,  under  the  influence  of  morphia.  When  he  awoke  he  was  per- 
fectly rational,  shook  hands  with  me,  and  talked  quite  cheerfully.  He 
said  he  Avas  feeling  better,  and,  to  try  him,  I  asked  him  in  an  off-hand 
manner  if  he  would  like  a  drink  of  wrater.  He  answered  "  No,"  in  a 
voice  which  showed  great  fear,  and  I  noticed  a  twitching  in  the  muscles 
of  his  throat  that  I  had  previously  seen  in  hydrophobic  patients.  In 
order  to  satisfy  myself  completely  in  regard  to  the  character  of  his 
disease,  I  told  him  that  he  would  have  to  get  up  and  take  a  drink.  He 
replied  that  he  would  try,  and  I  handed  him  a  glass  filled  with  water. 
As  he  took  the  tumbler  in  his  hand  he  trembled  violently  from  head 
to  foot,  and  the  muscles  of  his  throat  were  again  thrown  into  violent 
spasms.  He  made  several  unsuccessful  attempts  to  raise  the  glass  to 
his  lips,  but  finally,  with  an  almost  superhuman  effort,  he  succeeded. 
He  managed  to  gulp  down  three  swallows  of  the  water,  which  caused 
such  violent  convulsions  of  the  throat,  and  seemed  to  put  him  in  so 
much  agony,  that  I  took  it  from  him.  He  then  got  into  bed  and  a 
hypodermic  injection  of  morphia  was  given  him  and  he  sank  into  a 
peaceful  slumber.  Previous  to  my  arrival  he  had  had  many  severe 
spasms,  but  they  had  been  quieted  by  morphia,  and  I  advised  that  the 
administration  of  this  drug  should  be  continued.  He  died  the  day 
after  I  saw  him. 

Causes. — It  has  generally  been  supposed  that  hydrophobia  has  but 
one  source  in  the  human  subject,  and  that  is  inoculation  by  the  saliva 
of  an  animal  affected  with  rabies  ;  that  it  cannot  be  communicated  to 
one  individual  of  the  human  species  by  the  saliva  of  another  affected 
with  hydrophobia  ;  and  that  neither  dogs  nor  other  animals  can  be  in- 


HYDROPHOBIA.  649 

fected  by  inoculation  with  the  saliva  of  a  hydrophobic  man.  Magen- 
die's  experiment  as  to  the  latter  point  is  considered  by  many  to  be  of 
exceedingly  doubtful  value,  as  hydrophobia  was,  it  is  said,  prevailing 
among  dogs  at  the  time,  and  that  hence  the  animal  may  have  been 
bitten.  As  we  shall  see  hereafter,  these  suppositions  are  ail  more  or 
less  ill-founded. 

Thus  it  is  very  probable  that  the  saliva  of  healthy  animals,  the  dog 
especially,  is,  under  certain  circumstances,  capable  of  producing  hydro- 
phobia in  man  and  other  animals.  A  case  of  the  kind  is  recorded  in 
HufelancVs  Journal  of  December,  1839,  and  similar  ones  are  frequently 
met  with.  In  none  of  the  cases  I  have  witnessed  was  the  dog  which 
had  inflicted  the  wound  supposed  to  have  been  rabid.  In  one  case 
which  I  saw  in  this  city,  with  a  physician  whose  name  I  cannot  recall, 
the  patient,  a  stableman,  was  bitten  by  a  dog  that  was  to  all  appear- 
ance in  perfect  health.  In  the  case  reported  by  Dr.  Cook,  the  animal, 
a  bitch,  was  being  led  quietly  through  the  passage-way  of  the  house, 
when  the  child  became  entangled  in  the  chain,  fell  against  the  dog,  and 
was  bitten  apparently  in  anger.  The  animal  was  well  known,  and  was 
not  even  suspected  of  being  hydrophobic.  She  was  in  heat  ;  and  Dr. 
Cook  raises,  for  the  first  time  to  my  knowledge,  the  question  whether 
this  circumstance  renders  the  saliva  of  the  animal  capable  of  inducing 
hydrophobia  in  the  human  subject.  "With  a  view  of  throwing  as  much 
light  as  possible  on  the  subject,  he  consulted  the  records  of  Bellevue 
Hospital,  in  order  to  ascertain  the  facts  in  relation  to  a  man  who  died 
of  what  was  supposed  to  be  hydrophobia  from  the  bite  of  a  bitch  in 
heat.  The  result  of  his  inquiries  was  to  show  very  certainly  that  the 
man  did  die  of  hydrophobia  ;  that  the  animal  was  not  rabid,  and  that 
she  wss  in  heat. 

In  the  case,  the  details  of  which  have  just  been  given,  there  was  a 
good  deal  of  doubt  in  regard  to  the  identification  of  the  dog  which  in- 
flicted the  bite.  The  patient  said  he  had  been  bitten  "  by  a  little  black 
dog  belonging  to  a  baker  around  the  corner  on  the  avenue."  But  no 
such  dog  was  known,  and  there  was  no  baker  "  around  the  corner,"  on 
either  Second  or  Third  Avenue.  The  only  dog  that  was  known  to  have 
bitten  the  man  was  alive  and  well  on  the  7th  of  July,  two  weeks  after- 
ward. 

In  the  presenl  state  of  our  knowledge  it  is  useless  to  pursue  this 
point  of  the  inquiry  Further.  It  is  one  in  regard  to  which  certainty 
appears  to  be  impossible  of  attainment.  Fleming,'  however,  Beeras 
to  admit  the  possibility  of  an  animal  under  strong  sexual  excite- 
menl  being  able  to  communicate  hydrophobia  to  a  healthy  animal, 
when  he  says  : 

1 "  Dictionnaire  des  sciences  mldicales,"  article  "Rage,"  tome  slvii.,  p,   tr>.     Also 

\al  <l<  phyriologie,  tome  i ,  p.  17. 
*" Rabies  and  Bydrophobia,"  London,  1872,  p.  124. 


650  CEREBRO-SPINAL  DISEASES. 

"The  hypothesis  that  certain  ferments — an  improper  term — may 
be  developed  in  great  abundance  in  the  saliva  under  the  influence 
of  psychical  disturbance,  would  account  for  those  instances  in  which 
rabies  shows  itself  in  dogs  bitten  by  others  which  are  excited  or  furious 
by  sexual  desire,  though  themselves  healthy." 

It  would  appear  from  certain  experiments  that  the  saliva  is  the  only 
means  of  communication.  Thus  Dupuytren,  Breschet,  and  Magendie 
endeavored  to  convey  the  disease  by  injecting  the  blood  of  dogs  suf- 
fering from  rabies  into  the  veins  of  healthy  dogs,  but  always  unsuc- 
cessfully. The  flesh,  milk,  semen,  and  abdominal  secretions  were  like- 
wise found  not  to  be  media  for  transmission. 

On  the  other  hand,  Eckel,  of  Vienna,  after  several  failures,  inocu- 
lated a  dog  with  the  blood  of  a  man  who  was  affected  with  hydropho- 
bia. On  the  sixty-second  day  thereafter  the  animal  was  seized  with 
unmistakable  rabies  and  died.  Fleming,  however,  from  whom  I  quote 
this  statement,  says  that  it  must  not  be  forgotten  that,  at  the  time  of 
these  experiments,  rabies  was  raging  as  an  epizootic.  But  Bouley,1 
who  has  investigated  the  whole  subject  of  hydrophobia  with  great  abil- 
ity, declares  that  it  can  be  transmitted  only  by  inoculation,  and  the 
only  agent  which  has  the  power  of  communicating  it  is  the  saliva,  in 
which  alone  the  virus  exists.  Any  other  liquid  taken  from  a  rabid  ani- 
mal is  ineffective.  Inoculation  by  blood,  even  its  transfusion,  has  failed 
to  produce  any  results.  He  also  says  that  all  living  beings  affected 
with  hydrophobia  are  capable  of  transmitting  it  ;  that  is,  the  saliva  of 
all  rabid  animals  is  virulent,  it  matters  not  to  what  species  they  belong. 

Whether  or  not  it  originates  spontaneously  in  the  lower  animals,  it 
is  very  certain  that  it  has  no  other  origin  in  man  than  inoculation. 

Although  there  is  no  sure  evidence  on  the  point,  there  appears  to 
be  no  room  to  doubt  that  hydrophobia  may  be  communicated  by  inocu- 
lation from  a  person  affected  with  the  disease  to  an  unaffected  indi- 
vidual. Aurelianus,  Enaux,  and  Chaussier,  and  others  cited  by  Flem- 
ing, mention  instances  in  which  it  has  been  induced  in  persons  who 
have  accidentally  had  the  saliva  of  hydrophobic  patients  applied  to 
their  lips.  Fleming  2  states  that  in  1871  a  girl  named  Bence  died  in 
Liverpool  from  hydrophobia.  It  was  believed  she  had  not  been  bitten, 
but  the  death  of  her  little  brother,  from  the  disease,  occurred  about 
three  weeks  previously,  and  the  supposition  was  that  the  virus  had 
been  communicated  in  some  way  to  the  girl  through  a  wound  in 
her  foot. 

The  fact  that  hydrophobia  can  be  communicated  from  man  to  the 
lower  animals  is  sufficiently  well  established  by  the  experiments  of 
Magendie,  Breschet,  Earle,  and  Renault. 

1  "  Hydrophobia,"  by  II.  Bouley,  translated  from  the  French  by  A.  Liautaud,  M.  D., 
V.S.,  New  York,  1874,  p.  0. 

2  Op.  tit.,  p.  141. 


HYDROPHOBIA.  651 

The  wolf  is  said  to  be  the  most  dangerous  of  all  animals  when  rabid, 
for  the  reason  probably  that  it  seizes  the  neck  or  face,  parts  not  fully 
protected  by  clothing,  and  thus  the  saliva  is  not  so  apt  to  be  rubbed  off 
as  when  the  leg,  for  instance,  is  the  part  attacked. 

The  slightest  abrasion  of  the  skin  coming  in  contact  with  the  saliva 
may  be  sufficient  for  inoculation.  Cases  are  recorded  in  which  the  dis- 
ease has  resulted  from  dogs  licking  the  hand  or  face  on  which  there 
were  pimples  or  sores. 

Diagnosis. — That  protean  disease,  hysteria,  occasionally  puts  on  the 
semblance  of  hydrophobia.  Several  cases  of  the  kind  have  occurred  to 
me,  and,  in  all,  the  symptoms  were  in  general  character  very  much  like 
those  which  are  exhibited  by  genuine  hydrophobia,  though  in  some  re- 
spects, perhaps,  a  little  exaggerated.  It  will  in  these  and  similar  cases 
— the  result  of  fright  and  imagination — often  be  found  that  the  patient 
has  been  bitten  by  a  dog  not  long  before.  There  is  a  want  of  consist- 
ency about  the  symptoms  which  of  itself  is  sufficient  to  excite  suspicion 
as  to  the  real  character  of  the  phenomena.  Thus,  although  at  times 
the  attempt  to  swallow  will  excite  laryngeal  and  other  spasms,  these  do 
not  always  occur  under  similar  circumstances,  and  are  not  induced  by 
those  secondary  and  more  refined  influences,  such  as  the  sound  of  fall- 
ing water,  bright  lights  in  the  face,  excitations  applied  to  the  skin,  see- 
ing others  drink,  etc.,  which  so  generally  cause  them  in  the  real  dis- 
ease. There  are  not  the  same  anxiety  and  depression  in  the  simulated 
disease  as  in  the  real,  though  the  apparent  emotional  disturbance  is 
much  greater.  The  hysterical  patient  is  loud  in  the  expression  of  ap- 
prehensions, while  the  real  hydrophobic  one,  though  intensely  anxious 
and  terrified,  endeavors  to  prevent  others  perceiving  the  state  of  his  mind. 

The  history  of  the  case,  the  existence  of  the  hysterical  diathesis, 
and  the  fact  that  the  symptoms  come  on  soon  after  the  bite  without  any 
period  of  incubation,  will  further  aid  in  establishing  the  diagnosis  be- 
tween the  false  and  the  real  disease. 

The  last  case  of  the  simulated  disease  which  has  come  under  my  ob- 
servation was  that  of  a  policeman  whom  I  saw  in  consultation  with  Dr. 
S.  G.  Cook  in  the  summer  of  1874.  The  man  was  then  in  the  Park 
Hospital,  held  down  on  a  bed,  and  snapping  like  a  dog  at  every  person 
who  came  in  his  way.  At  the  sight  of  water  he  became  intensely  ex- 
cited, foamed  at  the  mouth,  and  went  through  a  series  of  fearful  con- 
tortions of  his  limbs.  But,  when  I  took  a  glass  of  water  in  my  hand 
and  told  him  in  a  commanding  voice  to  drink  immediately,  he  swallowed 
the  liquid  without  the  slightest  difficulty. 

The  bromide  of  potassium  in  large  doses  was  prescribed,  and  the 
ne\!  day  all  his  symptoms  had  disappeared.  <>n  inquiry,  it  was 
ascertained  thai  lie  had  keen  kitten  by  a  dog  several  days  before, 
and  that  his  comrades  had  frightened  him  by  their  inquiries  and  sug- 
gestions. 


652  CEREBRO-SPIXAL   DISEASES. 

The  fact  that  a  disease  resembling  hydrophobia  may  be  induced  by 
physical  derangement  and  by  mental  disturbance  especially  of  the  im- 
agination, and  that  death  may  be  the  consequence,  is  very  well  estab- 
lished, and  may  account  for  the  apparently  spontaneous  instances,  and 
for  those  cases  of  long  incubation  which  are  cited  by  authors. 

Thus  M.  Labadie  Lagrave l  quotes  from  Raymond  (de  Marseille)  the 
case  of  a  child  twelve  years  old  who  became  hydrophobic  without  known 
cause  and  died  at  the  end  of  ten  days.  Also  a  case  from  Rouppe  of  a 
sailor  who  had  convulsions  and  died  hydrophobic  without  known  cause, 
and  another  from  Pouteau  of  a  man  who  died  in  fifteen  hours  with 
symptoms  of  hydrophobia  which  had  ensued  on  a  violent  paroxysm  of 
anger. 

Berthier  s  refers  to  several  similar  cases  occurring  as  the  result  of 
menstrual  derangement. 

Fleming 8  cites  the  instance  of  a  woman  who  had  been  bitten  in  the 
face  and  who  was  admitted  to  the  Hotel-Dieu  in  Paris.  After  a  few 
days  she  was  cured  of  her  wounds  and  discharged.  Going  about  her 
usual  avocations  one  day  she  heard  a  man  exclaim,  "  She  has  not  gone 
mad,  then  !  "  From  that  time  she  could  not  swallow  liquids,  and  on  the 
same  day  was  readmitted  to  the  HCtel-Dieu,  and  this  time  to  die  of 
hydrophobia. 

The  following  case  is  also  given  by  Fleming:  "A  woman  in  the 
clinic  of  Dr.  Maisonneuve  had  been  bitten  by  a  dog,  which  was  supposed 
not  to  be  rabid,  and  the  injury  had  healed;  when  two  months  after  the 
accident  she  was  met  by  two  students,  who  had  been  with  the  doctor  at 
the  time,  and  who  asked  her  if  she  was  not  yet  mad.  Immediately  she 
was  seized  with  nervous  symptoms,  became  intensely  anxious  and  un- 
easy, and  went  into  the  hospital  in  the  belief  that  she  was  hydrophobic. 
She  was  put  under  the  care  of  M.  Laugier  and  the  following  day  was 
evidently  affected  with  the  disease;  hemiplegia  appeared,  with  a  vio- 
lent delirium,  accompanied  by  an  irrepressible  amount  of  fear,  and  she 
died  asphyxiated  in  forty-eight  hours." 

The  temperature  in  all  cases  of  pseudo-hydrophobia  that  I  have  wit- 
nessed was  not  above  the  normal  standard. 

Hydrophobia  has  been  confounded  with  tetanus,  and  some  writers 
have  regarded  it  as  a  modified  form  of  this  affection.  The  distinction 
is,  however,  so  well  marked  that  it  scarcely  seems  necessary  to  dwell 
upon  it.  The  facts  that  in  tetanus  the  spasms  are  tonic,  while  in 
hydrophobia  they  are  clonic  ;  that  in  the  first-named  they  are  mainly 
shown  as  regards  the  jaws  and  back,  while  in  the  latter  they  radiate 
from  the  throat ;  that  in  tetanus  the  mind  is  clear  throughout,  while 

1  Article  " Hydrophobic,"  in"Nouveau  dictionnaire  de  medecine  et  de  chirurgie  pra- 
tiques," tome  xviii.,  Paris,  1874,  p.  17. 

8  "  Des  nevroses  menstruellcs,"  Paris,  1874,  p.  169. 
»  Op.  cil.,  p.  176. 


HYDROPHOBIA.  653 

in  hydrophobia  more  or  less  mental  implication  is  always  present, 
will  suffice  to  render  any  mistake  in  the  diagnosis  of  the  two  diseases 
impossible. 

From  epilepsy  the  distinction  is  so  obvious  as  not  to  require  further 
mention. 

Prognosis. — There  is  no  authentic  instance  on  record  of  a  cure  of 
hydrophobia.  Several  such  have  been  reported,  but  inquiry  has  always 
shown  misstatement  or  error  somewhere.  The  fact  that  the  hysterical 
counterpart  has  several  times  been  regarded  as  the  real  disease,  is 
the  main  support  for  the  opinion  of  some  authors  that  the  affection  is 
curable. 

Several  years  ago  Dr.  Ligget,1  of  Maryland,  reported  a  case  of  hy- 
drophobia cured  by  calomel.  A  careful  examination  of  the  details  of 
this  case  excites  very  grave  doubts  in  my  mind  in  regard  to  its  really 
being  an  instance  of  the  disease  in  question. 

The  subject  was  a  negro-woman  who  had  been  bitten  about  two 
weeks  before  any  symptoms  were  manifested.  The  dog  was  lying 
quietly  in  the  yard,  and  bit  her  in  the  great-toe  as  she  was  teasing  him 
with  her  foot.  The  animal  was  at  once  chained  up,  and  died  in  two  or 
three  days  with  "  all  the  symptoms  of  rabies  canina  in  its  most  virulent 
form."  It  does  not  appear  that  the  doctor  saw  the  dog,  and  it  is  very 
probable  that  the  rigid  confinement  would  have  caused  the  animal  to 
exhibit  symptoms  which  would  easily  be  mistaken  by  laymen  for  those 
of  hydrophobia. 

Again,  the  period  of  incubation  was  unusually  short,  and  the  symp- 
toms, as  detailed  by  Dr.  Ligget,  are  clearly  not  those  of  hydrophobia. 
Thus,  although  he  repeatedly  states  that  there  was  inability  to  swallow 
liquids,  there  is  no  distinct  mention  made  of  the  pathognomonic  laryn- 
geal and  pharyngeal  spasms  which  occur  in  hydrophobia,  and  which  are 
so  frightful  in  character.  The  convulsions  all  appear  to  have  been  gen- 
eral, and  there  was  a  "  horror  "  of  water,  which  is  not  a  phenomenon  of 
the  true  disease.  For  these  reasons  I  am  constrained  to  believe  that 
the  disease  treated  by  drachm-doses  of  calomel  was  in  reality  one  of  hys- 
teria which  assumed  the  form  of  hydrophobia.  In  this  opinion  I  am 
sustained  by  an  eminent  medical  gentleman  residing  in  Dr.  Ligget's 
neighborhood,  who,  as  the  latter  admits,  declared  the  affection  to  be 
4<a  case  of  that  protean  disease,  hysteria,  simulating  hydrophobia." 
Calomel  has  been  repeatedly  tried  before  and  since  Dr.  Ligget's  case, 
but  without  effect. 

But,  although  the  prognosis  is  so  hopeless  in  the  developed  dia- 

,  it  is  much  m<>re  favorable  as  regards  the  probability  of  tin; 
supervention  of  hydrophobia  from  the  bites  of  rabid  animals ;  for,  of 

1  "Cas^  of  Hydrophobia  successfully  treated  with  Draehni-Doscs  of  Calomel,"  Amer- 
ican Journal  of  Medical  Science,  January,  18G0,  p.  B6. 


G54  CEREBRO-SPINAL  DISEASES. 

those  bitten  by  dogs  unmistakably  affected  with  the  disease,  not  more 
than  one  in  fifteen  becomes  successfully  inoculated.  This  liability 
differs  greatly  according  to  the  circumstance  of  the  part  being  cov- 
ered or  not.  The  wounds  of  the  face,  neck,  or  hands,  are  much  more 
likely  to  be  followed  by  hydrophobia  than  those  inflicted  on  the  legs 
or  feet,  where  the  virus  is  rubbed  off  by  the  clothing  before  the  teeth 
reach  the  flesh. 

The  bite  of  a  rabid  wolf  is  more  apt  to  be  followed  by  the  dis- 
ease than  the  bite  of  a  dog,  for  the  reason  that  the  first-named  gen- 
erally seizes  the  throat  or  face.  Thus,  Trolliet  states  that  at  Brives, 
in  France,  seventeen  persons  were  bitten  by  a  rabid  wolf,  of  whom 
ten  died  of  hydrophobia  ;  and,  of  twenty-three  bitten  by  another, 
thirteen  died. 

On  the  other  hand,  Hunter  states  that  on  one  occasion  a  dog  bit 
twenty  persons,  of  whom  only  one  was  inoculated.  Those  first  bitten 
by  a  rabid  animal  are  more  liable  to  have  hydrophobia  than  those  bit- 
ten subsequently,  when  the  poison  is  in  a  measure  exhausted.  Proba- 
bly the  most  dangerous  wounds  are  those  which  barely  penetrate  the 
epidermis,  and  in  which,  therefore,  the  venom  is  not  washed  away  by 
any  flow  of  blood. 

Morbid  Anatomy. — Within  the  last  few  years  the  study  of  the  mor- 
bid anatomy  of  hydrophobia  has  led  to  results  which  may  be  considered, 
at  least  for  the  present,  as  determining,  with  some  degree  of  exactness, 
the  situation  and  character  of  the  essential  lesions  of  this  terrible  dis- 
ease. 

In  1869  Meynert  examined  microscopically  the  spinal  cords  of  a  boy 
and  girl,  patients  at  Oppolzer's  clinic,  who  died  of  hydrophobia. 

In  the  first  case,  he  found  thickening  of  the  walls  of  the  spinal  ves- 
sels, amyloid  degeneration  and  nuclear  proliferation  of  the  cells  of  the 
neuroglia. 

In  the  second  case,  the  neuroglia  of  the  posterior  columns  of  the 
cord  was  hypertrophied,  through  swelling  of  the  stellate  bodies.  In 
the  antero-lateral  columns  there  were  granular  and  amyloid  degenera- 
tion, and  numerous  distended  blood-vessels. 

The  cortical  substance  of  the  brain  exhibited  the  presence  of  a  large 
number  of  lacunas  with  colloid  masses.  The  nerve-cells  of  this  part 
were  the  seat  partly  of  molecular  disintegration,  and  partly  of  sclerotic 
enlargement. 

Next  are  the  observations  of  Dr.  Clifford  Allbutt,1  who  examined 
the  nerve-centres  in  two  patients,  who  died  of  hydrophobia  while  in- 
mates of  the  Leeds  General  Infirmary.  Throughout  the  brain  and  spinal 
cord  there  were  evidences  of  great  vascular  congestion  with  transudation 
into  the  surrounding  tissue.     In  several  places  the  walls  of  the  vessels 

1  "Specimens  illustrating  the  Pathological  Anatomy  of  Hydrophobia,"  " Transactions 
of  the  Pathological  Society  of  London,"  vol.  xxiii.,  p.  16,  1872. 


HYDROPHOBIA.  655 

were  thickened  and  there  were  here  and  there  patches  of  incipient 
nuclear  proliferation.  There  were  also  hemorrhages  into  the  medulla 
oblongata.  In  many  places  there  was  a  refracting  material  to  be  seen 
outside  of  the  vessels,  which  probably  was  of  the  nature  of  a  coagulated 
fibrinous  exudation.  Finally,  Dr.  Allbutt  found  in  the  encephalon  occa- 
sionally, and  in  both  spinal  cords,  and  especially  in  both  medullas,  little 
gaps  caused  by  the  disappearance  of  nerve-strands  which  had  passed 
through  the  granular  degeneration  of  Clarke.  These  phenomena,  adds 
Dr.  Allbutt,  point  to  the  action  of  an  animal  poison  acting  primarily 
on  the  cerebro-spinal  nervous  system. 

Then  in  July,  1S74,  were  my  own  researches,1  made  at  Dr.  Hadden's 
request,  in  the  case,  the  details  of  which,  as  observed  during  life,  have 
just  been  given. 

As  preliminary  to  the  description  of  the  microscopical  appearances, 
it  may  be  stated  that,  on  removing  the  calvarium,  the  membranes  of 
the  brain  were  found  to  be  congested,  but  there  was  no  appearance  of 
serous  effusion  to  an  abnormal  extent  either  in  the  sub-arachnoidal 
space  or  in  the  ventricles.  The  substance  of  the  brain  was  only  slight- 
ly congested,  but  the  consistence,  especially  of  the  cortical  tissue,  was 
somewhat  less  than  normal.  The  cerebellum  appeared  to  be  healthy, 
as  did  also  the  pons  Varolii,  the  corpus  striatum,  the  optic  thalamus, 
and  other  ganglia,  with  the  exception  of  the  medulla  oblongata,  which 
seemed  to  be  slightly  softened.  The  membranes  covering  it  and  the 
upper  part  of  the  spinal  cord  were  congested. 

I  took  for  examination  (1)  portions  of  the  cortical  substance  of  the 
brain  ;  (2)  sections  of  the  corpus  striatum  ;  (3)  sections  of  the  optic 
thalamus  ;  (-4)  sections  of  the  cerebellum  ;  (5)  the  pons  Varolii  ;  (G)  the 
medulla  oblongata  ;  (7)  a  section  of  the  spinal  cord  at  the  level  of  the 
second  pair  of  cervical  nerves  ;  (8)  a  portion  of  the  pneumogastric 
nerve  from  the  neck : 

1.  Cortical  substance  of  the  brain. 

My  examinations  of  this  tissue  were  made  upon  specimens  which 
had  been  kept  in  absolute  alcohol  eighteen  hours,  in  glass  tubes  sur- 
rounded with  ice.  I  experienced  no  difficulty  in  cutting  sufficiently 
thin  sections.  In  all  the  sections  the  following  conditions  existed  (ob- 
ject-glass one-fourth  inch) : 

a.  The  blood-vessels  were  increased  in  size  and  number,  and  their 
walls  appeared  to  be  thickened. 

b.  There  were  minute  extravasations  of  blood  throughout,  in  some 
of  which  the  blood-disks  could  still  be  distinguished,  but  in  most  of 
them  they  wore  broken  down. 

c.  The  external  layer  of  nerve-cells  had  almost  entirely  been  re« 
placed  by  fatty  matter  in  (he  form  of  oil-globules.     The  cells  that  re- 

1  "  Pn lings  of  the  New  York  Neorologloa]  Society,"  July  7,  137t,  in  Psychological 

aiul  Mitdieo-Zegal  Journal,  September,  1874,  p.  189. 


656 


CEREBRO-SPINAL   DISEASES. 


mained  were  filled  with  a  highly-refracting  granular  material,  which 
was  also  oil  in  very  minute  particles.  None  of  these  cells  were  bi-nu- 
clear.  Amyloid  corpuscles  were  discovered  generally  at  the  junction 
of  this  with  the  next  stratum. 

d.  The  second  layer  of  cells  had  also  to  a  great  degree  been  re- 
placed by  fat,  but  not  to  the  same  extent  as  the  outer  layer.  It  is 
well  known  that  this  layer  is  composed  of  more  numerous  and  larger 
cells  than  the  outer  ;  but  there  was  no  doubt  of  their  atrophy  or  dis- 
appearance. 

e.  The  third  layer,  composed  of  large  cells,  was  scarcely  affected.  A 
few  oil-globules  were  seen,  and  occasionally  an  amyloid  corpuscle. 
The  remaining  strata  were  not  involved,  so  far  as  I  could  see,  to  the 
slighest  extent. 

In  Fig.  98  a  vertical  section  of  the  cortical  substance  is  seen:  1,  the 

Fig.  98. 


outer  or  peripheral  stratum  ;  2,  the  second  layer  ;  3,  the  third  layer  or 
large  cells. 

2.  The  corpus  striatum,  the  optic  thalamus,  and  the  cerebellum  were 
in  an  apparently  normal  condition,  though  there  was  some  evidence  of 
arterial  injection. 

3.  The  pons  Varolii  was  not  examined  in  the  fresh  state,  but  was 
placed  entire  in  a  solution  of  bichromate  of  potash  to  harden.  Subse- 
quently examined,  it  was  found  to  be  the  seat  of  extravasation  of 
blood,  and  the  vessels  were  enlarged  and  their  walls  thickened. 

4.  The  greater  portion  of  the  medulla  oblongata  was  also  placed  in 


HYDROPHOBIA.  657 

the  bichromate  of  potash  solution,  but  several  sections  were  made  after 
the  part  had  been  in  absolute  alcohol  surrounded  by  ice  for  twenty- 
four  hours. 

a.  The  first  of  these  was  made  through  the  olivary  bodies,  at  the 
level  of  the  floor  of  the  fourth  ventricle,  so  as  to  include  the  nuclei  of 
the  pneumogastric  and  hypoglossal  nerves. 

Numerous  extravasations  of  blood  could  be  seen  with  the  naked  eye, 
but  with  an  inch  objective  they  were  more  clearly  made  out.  The  ves- 
sels were  then  seen  to  be  enlarged  and  more  numerous  than  in  the  nor- 
mal condition.  The  gray  matter  forming  the  nuclei  of  the  pneumogas- 
tric and  hypoglossal  nerves  was  observed  to  be  of  a  distinctly  granular 
appearance,  and  the  roots  of  the  nerves  presented  a  like  characteristic. 
In  other  respects  the  section  exhibited  nothing  abnormal. 

b.  Examined  with  a  fourth-inch  objective,  this  granular  matter  of 
the  nuclei  was  seen  to  consist  of  oil-globules  and  amyloid  corpuscles. 
The  cells  were  ascertained  to  be  atrophied  both  in  size  and  numbers. 
Indeed,  they  had  almost  entirely  disappeared.  Of  course  it  was  not  pos- 
sible, in  a  fresh  and  unprepared  preparation,  to  form  any  definite  idea 
of  the  relative  proportion  of  nerve  to  neuroglia  cells,  but  the  deficiency 
of  all  cell-structure  was  very  remarkable.  (Fig.  99,  a,  oil-globules ; 
b,  amyloid  bodies  ;  c,  nerve-cells  ;  d,  blood-vessels.) 


Fig.  99. 


e.  The  nerve-roots,  when  examined  in  like  manner,  wen-  seen  to 
have  undergone  a  similar  change,  the  granular  matter  consisting  en- 
tirely of  fat,  mainly  in  the  form  of  oil-globules  (Fig.  100). 
43 


658 


CEREBRO-SPIXAL   DISEASES. 


Sections  made  immediately  below  the  level  of  the  point  of  the 
calamus  scriptorius,  so  as  to  include  the  main  root  of  the  spinal  ac- 
cessory nerve  and  its  nucleus,  exhibited  almost  exactly  the  same 
appearances. 

5.  The  Spinal  Corel — The  section  of  the  cord  was  made  at  a  point 
about  midway  between  the  first  and  second  cervical  nerves.  The  gray 
matter  of  the  anterior  and  posterior  horns  was  found  in  a  state  of  granu- 
lar and  fatty  degeneration,  the  cells  atrophied,  and  the  nerve-roots  in 


Fig.  101. 


a  similar  condition.  In  the  white  matter,  both  of  the  anterior  and 
posterior  columns,  there  was  nuclear  proliferation  of  the  neuroglia- 
cells  (Fig.  101). 

6.  The  peripheral  portion  of  the  pneumogastric  nerve,  carefully 
removed  by  my  assistant  and  placed  in  strong  alcohol,  exhibited  a  red 
appearance,  but  this  may  have  been  due  to  imbibition. 

Benedict,1  about  the  time  of  my  own  observations,  made  a  series 
of  researches  into  the  morbid  anatomy  of  hydrophobia  as  met  with  in 
dogs.     His  results  were — 

1.  The  vessels  situated  between  the  cerebral  convolutions  were 
distended  with  blood,  and  their  external  walls  were  coated  with 
an  exudation  of  a  highly  refractive  material  consisting  of  granules. 

2.  Numerous  cavities  were  found  to  exist  in  the  gray  matter  of  the 
brain,  and  these  were  filled  with  a  like  granular,  highly  refracting  ma- 
terial similar  to  that  found  in  the  walls  of  the  vessels. 

1  "Die  anatomisehen  Veranderungen  bei  der  Lyssa  des  Hundes,"  Wiener  medicinische 
Prcsse,  July  5,  1874. 


HYDROPHOBIA.  659 

3.  Masses  of  myeline,  indicative  of  softening,  and  chemical  changes 
of  the  nerve-tissue,  were  also  discovered. 

Benedict  regards  the  appearances  as  identical  with  those  which 
Lockhart  Clarke  has  considered  as  indicating  granular  degeneration. 

From  the  foregoing  data  it  will  be  perceived  that  at  last  something 
definite  has  been  ascertained  relative  to  the  morbid  anatomy  of  hydro- 
phobia. Whether  we  regard  the  condition,  according  to  Benedict,  as  an 
acute  exudative  inflammation,  or  as  a  granular  degeneration,  is  of  no  con- 
sequence so  far  as  the  facts  are  concerned.  Whether  on  the  one  hand 
the  granular  matter  is  an  exudation,  or  whether  it  results  from  degenera- 
tion of  the  nerve-tissue,  are  points  which  will  probably  ere  long  be 
cleared  up.  My  own  view  is  in  accordance  with  that  of  Lockhart  Clarke, 
who,  detecting  a  like  change  in  other  affections  of  the  nerve-centres, 
views  it  not  as  an  exudation  but  as  a  degeneration. 

As  to  the  gross  lesions,  congestion  of  the  brain  and  spinal  cord  has 
been  found  by  many  observers. 

Sometimes  the  nerves  at  the  wound  are  inflamed,  but  this  is  not  a 
uniform  occurrence.  The  eighth  pair  has  been  found  to  present  a  pink- 
ish appearance  in  some  cases.  In  four  cases  in  which  the  blood  was 
examined  by  Schivardi,1  infusoria  of  the  genera  bacterium,  monas, 
vibrio,  and  torula,  existed. 

The  fauces,  pharynx,  larynx,  trachea,  and  lungs,  are  generally  found 
reddened  and  congested,  as  much  from  the  asphyxia  as  from  any  spe- 
cific influence  of  the  disease. 

Pathology. — Even  if  we  had  no  information  relative  to  the  morbid 
anatomy  of  hydrophobia,  no  one  who  has  ever  witnessed  a  case  could 
fail  to  perceive  the  implication  of  the  hemispheres,  the  medulla  oblon- 
gata, and  the  spinal  cord.  The  hallucinations  and  other  mental  phe- 
nomena point  to  the  hemispheres  ;  the  irregular  action  of  the  respira- 
tory muscles  and  the  heart,  together  with  the  gastric  derangement  and 
pharyngeal  convulsions,  indicates  the  implication  of  the  pneumogastric 
nerves  ;  and  {lie  spasms  of  the  larynx  point  to  the  origins  of  the  spinal 
accessory  nerves  in  the  spinal  cord.  Since  we  have  arrived  at  some 
degree  of  exactness  relative  to  the  lesions  in  the  disease,  we  cannot 
fail  to  have  our  conviction  on  these  points  strengthened. 

The  nature  of  1 1 1 ; »  virus  is  unknown.  It  is  probably  of  the  nature 
of  a  ferment,  hut  this  cannol  be  regarded  as  satisfactorily  proved. 

In  1830,  Dr.  Marochetti  observed,  in  the  Ukraine,  that  during  the 
formative  period  of  hydrophobia  small  vesicles  or  pustules  formed  un- 
der the  tongue,  and  that,  if  these  were  opened  and  cauterized,  the  fur- 
ther development  of  the  disease  was  prevented.  I  have  never  been 
able  to  find  these  formations,  but  they  were  recognized,  two  years  after 
Marochetti  published  his  account,  by  Magistral,  in  France.  This  latter 
opened  and  cauterized  them  in  the  manner  recommended  by  Marochetti 

1  "Oljscr\;itioiis  nouvellei  BUT  la  rage,"  Besancon,  1808.  p.  28. 


660  CEREBRO-SPINAL  DISEASES. 

in  ten  cases,  in  five  of  which,  nevertheless,  the  affection  went  on  to 
full  development,  and  the  patients  died.  I  am  not  aware  that  any  one 
else  has  discovered  these  pustules. 

For  full  details  relative  to  hydrophobia  as  it  appears  in  dogs,  I 
must  refer  the  reader  to  the  late  Mr.  Youatt's  excellent  book  on  canine 
madness,  and  to  the  more  recent  and  thorough  treatise  of  Fleming.  I 
may  state  that  it  is  very  clearly  established  that  canine  rabies  is  not 
so  frequent  in  very  hot  as  it  is  in  temperate  or  cold  weather ;  that  it 
is  not  induced  by  thirst  or  improper  food,  or  by  preventing  copulation. 

Is  hydrophobia  primarily  a  disease  of  the  nerve-centres  or  a  blood- 
disease  ?  I  suppose  it  is  utterly  impossible,  in  the  present  state  of  our 
knowledge,  to  answer  such  a  question.  It  may  start  as  a  blood-disease 
and  end  as  a  nerve-disease.  Blood-diseases  lead  to  structural  changes 
of  various  organs  of  the  body,  and  the  nerve-centres  are  likewise  in- 
volved to  a  considerable  extent.  Is  it  not  worth  while  to  call  attention 
to  the  numerous  instances  of  blood-diseases  which  produce  structural 
changes  ?  Hydrophobia  may  be  a  blood-disease,  and  yet  afterward 
be  succeeded  by  changes  in  the  nerve-centres.  It  is  not  necessary  to 
suppose  that  hydrophobia  is  a  nerve-disease  from  the  beginning.  It  is 
perfectly  possible,  however,  that  it  may  be,  and  there  are  a  great  many 
instances  which  can  readily  be  adduced  in  proof  of  this  assertion. 
Take  tetanus  for  exanmle.  Very  few  pathologists  pretend  to  say  that 
tetanus  is  a  blood-disease.  It  is  a  disease  propagated  through  the 
nerve-tissue  starting  from  injury  of  a  peripheral  nerve,  and  inducing 
structural  changes  in  the  spinal  cord.  Dr.  Lockhart  Clarke,  as  we  have 
seen,  has  ascertained  in  a  number  of  cases  that  the  essential  condition 
of  tetanus  is  a  granular  degeneration  of  the  cord,  and  that  is,  probably, 
only  the  beginning  of  the  fatty  degeneration  I  find  in  hydrophobia, 
and  yet  there  is  no  suspicion  of  blood-poisoning  in  tetanus.  Hydro- 
phobia presents  many  analogies  to  tetanus,  not  only  in  its  morbid  anat- 
omy but  in  its  natural  history. 

Epilepsy  can  be  caused  by  injuries  to  peripheral  nerves.  I  had  a 
case  some  years  ago  of  a  lady  who  wounded  her  thumb,  and  six  months 
afterward  she  had  epileptic  paroxysms,  which  were  preceded  by  an  aura 
originating  in  the  cicatrix.  And  if  epilepsy — which  is  another  one  of 
the  spasmodic  diseases — can  be  induced  by  a  simple  wound,  why  not 
hydrophobia  ?  So  that  we  have  examples  of  analogous  diseases  caused 
by  wounds  of  nerves,  without  the  necessity  of  supposing  the  blood  to 
be  primarily  affected. 

Still,  there  cannot  be  much  doubt  that  the  poison  in  the  saliva,  and 
not  the  wound  made  by  the  animal's  teeth,  is  the  essential  influence 
producing  hydrophobia.  It  is  not  at  all  certain,  however,  that  the  lat- 
ter may  not  in  some  cases  produce  a  modification  of  the  characteristics 
of  the  disease,  perhaps  causing  those  tetanoid  phenomena  which  are  oc- 
casionally present. 


HYDROPHOBIA.  661 

Treatment. — The  measures  of  treatment  relate  to  those  proper  im- 
mediately after  the  infliction  of  the  wound,  with  the  view  of  preventing 
the  development  of  the  disease,  and  those  advisable  after  the  affection 
is  unmistakably  manifested. 

Under  the  first  category  comes  excision,  which  should  be  performed 
as  soon  as  possible,  and  which  is  probably  the  best  of  all  prophylactics. 
The  operation  should  not  be  done  with  a  niggardly  hand,  but  every  part 
with  which  the  teeth  of  the  animal  have  come  in  contact  should  be  re- 
moved, as  well  as  the  tissue  into  which  the  poison  may  have  become 
infiltrated.  Previous  to  the  operation,  in  fact  as  soon  as  the  wound 
has  been  received,  a  tight  ligature  should  be  bound  around  the  limb 
immediately  above  the  injury,  and,  after  the  knife  has  done  its  work, 
cupping-glasses  should  be  applied  over  the  spot,  till  the  tissues  in  the 
vicinity  are  thoroughly  drained  of  blood.  I  have  performed  excision, 
for  the  wounds  received  from  dogs  certainly  rabid,  eleven  times,  and 
always  with  the  effect  of  preventing  hydrophobia. 

Cauterization  may  be  performed  instead  of  excision,  and  is  preferred 
by  some  practitioners.  Mr.  Youatt  used  it  with  over  four  hundred  per- 
sons bitten  by  rabid  animals,  and  never  unsuccessfully.  Four  times  he 
employed  it  on  himself,  but  there  is  a  strong  probability  that  the  prac- 
tice at  last  failed  with  Mr.  Youatt  himself,  for  he  committed  suicide 
while  supposed  to  be  suffering  from  the  initial  symptoms  of  hydropho- 
bia. 

He  preferred  the  nitrate  of  silver  as  an  escharotic.  Others  have 
made  use  of  the  actual  cautery,  caustic  alkalies,  the  mineral  acids, 
arsenic,  chloride  of  zinc,  and  carbolic  acid.  I  have  employed  cauteriza- 
tion seven  times — four  with  the  nitrate  of  silver  and  three  with  the 
actual  cautery — upon  persons  bitten  by  rabid  dogs,  and  always  with 

BUCCl 

Mr.  Youatt  at  one  time  had  faith  that  the  Scutellaria  lateriflora,  or 
Bcullcap,  was  a  preventive.  He  moistened  three  pieces  of  tape  with 
the  saliva  of  a  rabid  dog,  and  inserted  them  as  rowels  into  the  skin  of 
three  dogs.  To  two  of  these  he  gave  Scutellaria  combined  with  bella- 
donna, while  the  third  was  left  to  itself.  On  the  twenty-ninth  day 
after  the  inoculation  this  latter  became  rabid,  while  the  others,  several 
months  afterward,  were  alive  and  well. 

Notwithstanding  this  experience,  it  would  not  be  justifiable  in  the 
physician  to  negled  performing  either  excision  or  cauterization  as  soon 
as  possible  after  the  reception  of  the  bite.  Even  if  several  weeks  or 
months  hive  elapsed,  one  or  the  other— preferably  excision— should  be 
performed. 

The  researches  of  Pasteur  relative  to  the  production  and  prevention 
of  hydrophobia  have  not  yet,  in  my  opinion,  led  to  any  definite  results. 
It  would  appear,  Prom  accounts  that  have  reached  as  from  France, thai 

many   ]><  rsons    inoculated    after    Pasteur's    method    have   subsequently 


662  CEREBROSPINAL   DISEASES. 

died  of  hydrophobia,  while  it  is  very  certain  that  many  who  have  been 
inoculated  in  Pasteur's  Institute  in  Paris  had  not  previously  been 
bitten  by  rabid  animals.  In  this  country  such  statistics  as  have  been 
published  are  to  the  like  effect.1  It  would  certainly,  therefore,  be  pre- 
mature, in  the  present  state  of  our  knowledge,  to  give  an  adhesion  to 
the  Pasteur  method.  On  the  contrary,  after  due  consideration,  I  am 
inclined  to  express  the  opinion  that  it  is  not  so  sure  a  preventive  of 
hydrophobia  as  is  early  excision  or  cauterization.  "Were  I  myself  so 
unfortunate  as  to  be  bitten  by  a  hydrophobic  animal,  I  would  not  sub- 
ject myself  to  inoculation  after  the  process  in  question. 

As  to  the  treatment  of  the  fully-developed  disease,  there  is  noth- 
ing, in  my  opinion,  which  has  hitherto  succeeded  in  arresting  its 
onward  course.  Cases  of  cure  have  been  reported,  but,  as  already 
stated,  they  are  open  to  the  suspicion  of  not  being  true  instances  of 
the  disease. 

Excessive  bloodletting  has  been  reported  as  a  successful  remedy  ; 
injection  of  warm  water  into  the  veins  dissipated  the  paroxysms  in  a  case 
reported  by  Magendie,  the  patient,  however,  dying  ;  and  nearly  every 
stimulant,  narcotic  and  sedative,  in  the  materia  medica  has  been  used. 
In  the  case  which  I  saw  with  Dr.  Cook,  and  which  has  already  been 
cited,  the  hydrate  of  chloral  was  administered.  The  effect  certainly 
was  to  mitigate  the  severity  and  frequency  of  the  spasms,  but  it  was, 
as  Dr.  Cook  states,  given  too  late  in  the  course  of  the  disease  to  pro- 
duce any  permanently  curative  result.  In  the  present  state  of  our 
knowledge  I  should  be  more  disposed  to  rely  on  the  hot-air  bath  at  a 
temperature  of  about  200°  Fahr.,  and  the  administration  of  hydrate  of 
chloral  in  large  doses  frequently  repeated,  than  on  any  other  plan 
of  treatment.  In  Dr.  Cook's  case  the  Turkish  bath  was  proposed,  but 
the  parents  of  the  child  would  not  consent  to  its  use.  Hypodermic 
injections  of  morphia  and  atropia  may  be  used  with  some  advantage 
to  mitigate  the  force  of  the  paroxysms. 

Before  concluding  my  remarks  on  hydrophobia,  it  is  proper  to 
allude  to  the  attempts  of  Dr.  Schivardi,9  of  Milan,  to  cure  the  disease 
by  the  primary  galvanic  current.  In  one  case  the  current  was  feeble, 
and  was  continued  for  nineteen  hours.  Great  improvement  ensued  ; 
the  oppression  disappeared,  and  the  dysphagia  was  entirely  relieved. 
Through  some  misunderstanding,  advantage  was  not  taken  of  these 
ameliorations,  and  the  patient  was  allowed  to  die. 

In  the  other  case,  which  was  one  of  undoubted  hydrophobia,  oc- 
curring in  a  girl  nine  years  old,  the  current  from  twenty-two  Daniell's 
cells  was  employed.  The  current  was  passed  from  the  soles  of  the 
feet  to  the  forehead  for  fifty-eight  hours  almost  continuously,  and  the 
duration  of  the  disease  prolonged  to  seven  days  and  seven  hours,  when 

1  See  Medical  and  Surgical  Reporter,  July  5  and  October  25,  1890. 

2  "  Observations  nouvelles  sur  la  ra^e." 


EPILEPSY.  663 

the  patient  died.    During  the  last  two  days  there  were  no  hydrophobic 
symptoms. 

Further  trials  are  necessary  before  the  therapeutical  value  of  gal- 
vanism in  hydrophobia  can  be  ascertained. 


CHAPTER  II. 

EPILEPSY. 


Epilepsy,  although  only  a  symptom  of  a  morbid  condition,  must  for 
the  present  be  considered  as  a  disease,  for  the  reason  that  we  are  not 
able  to  designate  with  certainty  its  exact  seat,  or  the  nature  of  the 
lesion  which  exists.  It  is  characterized  by  paroxysms  of  more  or  less 
frequency  and  severity,  during  which  consciousness  is  lost,  and  which 
may  or  may  not  be  marked  by  slight  spasm,  or  partial  or  general  con- 
vulsions, or  mental  aberration,  or  by  all  of  these  circumstances  collec- 
tively. The  essential  element  of  the  epileptic  paroxysm  is  loss  of  con- 
sciousness. Without  that  there  is  no  true,  fully -formed  epileptic  par- 
oxysm. 

Symptoms. — Although  in  many  cases  there  are  no  precursory  phe- 
nomena, it  often  happens  that  there  are  indications  of  an  approaching 
attack.  These  are  exceedingly  variable  in  character  and  situation. 
They  may  consist  of  pain  in  the  head,  a  sensation  of  constriction  or 
fullness,  vertigo,  noises  in  the  ears,  a  feeling  as  if  the  ears  are  stopped 
with  cotton  or  water,  flashes  of  light,  or  sudden  blindness,  illusions  or 
hallucinations  of  any  of  the  senses — irritability  of  temper,  extraordinary 
cheerfulness,  difficulties  of  speech,  pains  in  various  parts  of  the  body, 
especially  in  the  stomach,  bowels,  or  ovaries,  sensations  of  numbness 
or  of  tingling,  or  of  an  indescribable  character,  which  begin  in  an  ex- 
tremity or  in  some  other  region,  and  appear  to  pass  rapidly  to  the  head 
— a  feeling  of  constriction  in  the  throat,  vomiting,  sudden  evacuation  of 
the  bladder  or  rectum,  erections  of  the  penis,  with  or  without  the  sexual 
orgasm,  and  discharge  of  semen,  with  many  others  of  almost  every  pos- 
sible description. 

The  prodromata  may  precede  the  attack  by  a  considerable  period, 
hul  usually  are  only  a  few  moments  in  advance  of  it.  Indeed,  often 
the  interval  is  so  short  that  they  may  be  regarded  as  a  part  of  the 
par<>\\  sin. 

The  sensations  of  numbness  or  tingling,  or  of  an  electric  shook,  as  a 
sharp  stab,  or  Mow,  or  pain,  which  precede  the  attack  and  which  origi- 
nate in  differenl  parts  of  the  body,  and  in  some  cases  seem  to  run  rap- 
idly toward  tie  head,  are  called  anna.  Sometimes  this  aura  is  fixed, 
and  may  consist  of  various  derangements  '  >f  Bensatii  »n  besides  those  above 


664  'CEREBRO-SPtNAL  DISEASES. 

mentioned.  In  a  number  of  my  patients  it  has  been  a  sensation  at  the 
pit  of  the  stomach,  such  as  that  produced  by  a  slight  feeling  of  hunger 
or  of  anxiety.  Again,  it  has  consisted  of  a  sharp  impression  on  the 
tongue;  at  others  of  a  subjective  sense  of  smell,  and  again  colored 
visions,  or  hallucinations  of  sight. 

In  regard  to  these  aurae  of  colors,  Dr.  Hughlings  Jackson l  has  made 
some  interesting  observations.  He  finds  that  red  is  the  color  which  is 
usually  seen  first,  though  the  others  may  follow  in  such  rapid  succession 
as  to  present  an  image  of  all  the  primary  colors.  Loss  of  the  power  to 
see  colors  (color-blindness)  is  generally  first  shown  as  regards  red;  and 
if  this  affection  advances,  the  insensibility  is  progressively  shown  tow- 
ard the  violet  end  of  the  spectrum.  So  in  the  epileptic  chromatic 
hyperesthesia,  the  formation  of  colors  is  in  the  same  direction,  and 
hence  red  is  first  perceived  and  violet  last — theoretically,  at  least,  for 
there  are  not  yet  sufficient  data  collected  to  enable  us  to  speak  with 
any  degree  of  certainty  on  the  subject.  There  are  exceptions,  how- 
ever, for  Dr.  Jackson  cites  the  case  of  one  of  his  patients  who  always 
saw  blue  just  before  an  attack.  In  my  own  experience,  red  has  been 
invariably  the  predominating  color,  and  in  most  cases  the  only  one. 
The  case  of  the  gentleman  who,  just  before  his  paroxysm  of  epilepsy, 
saw  an  old  woman  clothed  in  red  approach  him,  with  a  stick  raised  in  a 
threatening  manner,  and  the  fit  coming  on  as  soon  as  the  blow  fell  on 
his  head,  is  well  known.  Two  similar  instances  have  come  under  my 
own  notice. 

Other  derangements  of  sight  may  coexist  with  the  chiomatism  as 
epileptic  aura?.  Thus,  Sauvages a  mentions  the  fact  that  a  woman  sub- 
ject to  epilepsy  saw  during  the  paroxysm  dreadful  spectres,  and  that 
real  objects  appeared  magnified  to  an  extraordinary  degree  ;  a  fly 
seemed  as  large  as  a  fowl,  and  a  fowl  appeared  equal  in  size  to  an  ox. 
In  colored  objects,  green  predominated  with  her,  a  fact  which  Ferrier 
states  he  has  met  with  in  other  convulsive  diseases.  He  also  states 
that  a  very  intelligent  boy,  who  was  under  his  care  for  convulsions  of 
the  voluntary  muscles,  when  he  looked  at  some  large  caricatures,  glar- 
ingly colored  with  red  and  yellow,  insisted  on  it  that  they  were  covered 
with  green,  till  his  paroxysm  abated,  "  during  which  his  intellects  had 
not  been  at  all  affected." 

A  young  lady,  who  had  overtasked  her  mind  at  school,  was  thrown 
thereby  into  what  I  regarded  as  a  more  or  less  hysterical  condition,  but 
which  some  authorities  would  probably  consider  epileptic.  She  saw 
spectres  of  various  kinds  all  day,  but  every  real  object  at  which  she 
looked  appeared  to  be  of  an  enormous  size:  a  head,  for  instance,  seemed 
to  be  several  feet  in  diameter,  and  little  children  looked  like  giants. 

1  British  Medical  Journal,  February  1,  1874. 

2  Reported  by  Ferrier,  in  "Ad  Essay  toward  a  Theory  of  Apparitions,"  London,  1813, 
P.  86. 


EPILEPSY.  665 

When  I  took  out  my  watch,  while  examining  her  pulse,  she  remarked 
that  it  was  as  large  as  the  wheel  of  a  carriage. 

In  the  case  of  a  young  gentleman,  now  under  my  care  for  epilepsy, 
the  attacks  are  invariably  preceded  by  a  period  which  lasts  several 
hours  and  sometimes  a  whole  day,  during  which  he  "sees  small." 
Every  thing  appears  to  be  of  infinitesimal  size.  This  phenomenon  I  have 
never  seen  noted  by  any  other  writer  on  epilepsy. 

Aurae  connected  with  the  sense  of  hearing  are  uncommon,  except 
such  as  merely  consist  of  tinnitus — roaring,  buzzing,  singing,  etc. — 
these  are  often  met  with.  But  in  one  case  there  were  distinct  hallu- 
cinations of  hearing  preceding  the  attack,  the  patient  always  fancying 
that  he  heard  his  name  repeatedly  called. 

An  aura  may  be  entirely  manifested  by  dreams  or  delusions.  As  an 
instance  of  the  first  I  quote  the  following  remarkable  case  from  my  trea- 
tise on  "  Sleep  and  its  Derangements."  The  patient  occasionally  visits 
me  for  medical  advice,  but  has  had  no  epileptic  paroxysm  for  over  four 
years. 

"  A  lady  of  decided  good  sense  had  an  epileptic  seizure,  which  was 
preceded  by  a  singular  dream.  She  had  gone  to  bed  feeling  somewhat 
fatigued  with  the  labors  of  the  day,  which  had  consisted  in  attending 
three  or  four  morning  receptions,  winding  up  with  a  dinner-party.  She 
had  scarcely  fallen  asleep  when  she  dreamed  that  an  old  man  clothed 
in  black  approached  her,  holding  an  iron  crown  of  great  weight  in  his 
hands.  As  he  came  nearer  she  perceived  that  it  was  her  father,  who  had 
been  dead  several  years,  but  whose  features  she  distinctly  recollected. 
Holding  the  crown  at  arm's  length,  he  said:  '  My  daughter,  daring  my  life- 
time I  was  forced  to  wear  this  crown;  death  relieved  me  of  the  burden, 
but  it  now  descends  to  you.'  Saying  which,  he  placed  the  crown  on 
her  head  and  disappeared  gradually  from  her  sight.  Immediately  she 
felt  a  great  weight  and  an  intense  feeling  of  constriction  in  her  head. 
To  add  to  her  distress  she  imagined  that  the  rim  of  the  crown  was  stud- 
ded on  the  inside  with  sharp  points  which  wounded  her  forehead  so  that 
the  blood  streamed  down  her  face.  She  awoke  with  agitation,  excited, 
but  felt  nothing  uncomfortable.  Looking  at  the  clock  on  the  mantel- 
piece, she  found  that  she  had  been  in  bed  exactly  thirty-five  minutes. 
She  returned  to  bed  and  soon  fell  asleep,  but  wras  again  awakened  by  a 
similar  dream.  This  time  the  apparition  reproached  her  for  not  being 
willing  to  wear  the  crown.  She  had  been  in  bed  this  last  time  over 
three  hours  before  awakening.  Again  she  fell  asleep,  and  again,  at 
broad  daylight,  was  awakened  by  a  like  dream. 

"She  now  got  up,  took  a  bath,  and  proceeded  to  dress  herself,  with 
her  maid's  assistance.  Recalling  the  particulars  of  her  dream,  she  rec- 
ollected that  she  had  heard  her  father  say  one  day  that  in  his  youth, 
while  in  England,  bis  native  country,  he  had  been  Bubjeci  to  epileptic 
convulsions,  consequent  on  a   fall   from   a  tree,  and  thai  he  bad  been 


666  CEREBROSPINAL  DISEASES. 

cured  by  having  the  operation  of  trephining  performed  by  a  distin- 
guished London  surgeon. 

"  Though  by  no  means  superstitious,  the  dreams  made  a  deep  im- 
pression upon  her,  and,  her  sister  entering  the  room  at  the  time,  she 
proceeded  to  detail  them  to  her.  While  thus  engaged  she  suddenly 
gave  a  loud  scream,  became  unconscious,  and  fell  upon  the  floor,  in  a 
true  epileptic  convulsion.  This  paroxysm  was  not  a  very  severe  one. 
It  was  followed  in  about  a  week  by  another,  and,  strange  to  say,  this 
was  preceded  as  the  first  by  a  dream  of  her  father  placing  an  iron  crown 
on  her  head,  and  of  pain  being  thereby  produced." 

Subsequently  this  lady  had  two  other  attacks,  at  intervals  of  several 
months,  and  both  were  preceded  by  the  dream  of  the  iron  crown. 

In  the  case  of  a  gentleman  formerly,  under  my  treatment  for  epi- 
lepsy, the  fits  were  invariably  preceded  by  dreams  of  troubles  of  the 
head,  such  as  decapitation,  hanging,  perforation  with  an  auger,  etc. 

It  is  probable  that  in  such  cases  as  the  foregoing,  the  dream  is  ex- 
cited, as  dreams  often  are,  by  derangements  of  sensibility,  which  are 
themselves  the  aurae. 

In  some  cases  the  aurre  are  entirely  psychical,  consisting  of  illusions, 
hallucinations,  or  delusions.  Delusions  are  not  common  as  aura,  I 
have,  however,  had  one  case  in  a  lady,  who  had  an  epileptic  seizure 
immediately  after  hearing  of  the  death  of  a  gentleman  to  whom  she  was 
engaged  to  be  married,  and  whose  subsequent  paroxysms  were  almost 
always  preceded  by  the  delusion  that  she  was  going  to  be  killed.  There 
was  no  exaggeration  of  motility,  but  the  delusion  was  firmly  held  and 
acted  upon,  to  the  extent  that  she  would  give  away  her  effects,  and 
make  other  preparations  for  her  death.  The  following  day  the  fit 
usually  occurred,  although  sometimes  it  was  delayed  for  two  days. 

Delasiauve,1  of  two  hundred  and  sixty-four  cases,  found  the  parox- 
ysms unannounced  in  one  hundred  and  one,  and  with  precursory  phe- 
nomena in  one  hundred  and  eighty-three.  The  prodromata  were  im- 
mediate in  one  hundred  and  fifty  cases.  These  he  divides  into  seven 
categories,  as  follows.  It  is  to  be  recollected  that  cases  may  appear  un- 
der one  or  more  categories,  according  as  the  prodromata,  as  is  often  the 
case,  are  met  with  simultaneously  in  different  parts  of  the  body  : 

First  Series. — Precursory  Signs  in  the  Head. — Seventy-five  cases. 

Vertigo,  flashes  of  light 33 

Headache,  weight  in  the  head 15 

Heat  of  face 3 

Various  localized  sensations , 13 

Indefinite  sensations 1 

Illusions,  hallucinations,  and  other  sensorial  aberrations 9 

Rotation  of  the  head  or  of  the  eyes 5 

Grinding  of  the  teeth,  derangement  of  the  motility  of  the  tongue 2 

Tendency  to  sleep 1 

Constriction  of  the  throat S 

1  "  Trait6  de  l'epilepsie — histoire — traitement — medecine  legale,"  Paris,  1854,  p.  47. 


EPILEPSY.  667 

Second  Series. — Precursory  Signs  in  the  Throat, — Twenty-two 
cases. 

Oppression  of  the  chest  and  sense  of  suffocation 9 

Sensation  of  a  ball  or  of  motion  in  the  pectoral  region 2 

Shivering  sensation  of  cold  or  of  an  aura 5 

Pain  or  heat , 4 

Palpitations,  spasms 2 

Third  Series. — Precursory  Signs  in  the  Abdomen. — Thirty -two 
cases. 

Pain  with  or  without  oppression,  eructations,  vomiting 13 

Intestinal  or  uterine  colic 3 

Sensation  of  a  ball 3 

Sensation  of  cold,  of  a  vapor,  etc 6 

Stomachal  heat 1 

Undefinable  sensations 6 

Fourth  Series. — Precursory  Signs  in  the  Extremities. — Ninety 
four  cases. 

Numbness,  contractions,  jerkings,  retractions,  cramps,  formications,  etc. .  36 

Pain  with  or  without  spasms 13 

Tremblings 10 

Aura  or  phenomena  approaching  thereto 20 

Undefinable  sensations 15 

Fifth  Series. — Precursory  Signs,  consisting  of  General  and  Un- 
definable Sensations. — Twenty-two  cases. 

General  agitation  or  rotation  of  the  body 8 

Condition  of  discomfort,  fainting,  etc 6 

Vague  sensations 7 

Muioseness 1 

Sixth  Series. — Precursory  Signs  situated  in  the  Genital  Organs. 
— Five  cases,  such  as  retraction  of  the  testicles,  aura  starting  from  the 
testicles  and  spermatic  cords,  sensations  located  in  the  uterus,  etc. 

Seventh  Series. — Exceptional  Cases. — Desire  to  defecate,  to  uri- 
nal-', profuse  perspiration,  etc. 

The  Pabozysm. — Great  differences  are  observed  in  the  character 
and  severity  of  the  paroxysm.  Ordinarily  two  varieties  are  recognized) 
the  petit  nnil  or  slight  attack,  and  the  grand  mal  or  severe  seizure. 
The  first  is  unattended  by  marked  spasm  or  agitation;  the  latter  is 
characterized  by  more  or  less  violent  tonic  and  clonic  convulsions. 
These  divisions  air,  however,  not  regarded  as  sufficiently  precise  by 

those  who  have  studied  the  disease  in  question  with  care  and  preoision, 
and  more  minute  classifications  of  the  phenomena  of  the  epileptic  par- 
oxysm have  accordingly  been  made.  The  one  which  1  have  used  in  my 
lectures  at  the  University  Medical  College  feu  several  years  past  is  less 


668  CEREBRO-SPINAL   DISEASES. 

complex  than  some  others,  and  embraces  all  the  known  varieties.     It 
is  as  follows  : 

1.  Momentary  unconsciousness  without  marked  spasm. 

2.  Unconsciousness  with  evident  though  local  spasm. 

3.  Unconsciousness  with  general  tonic  and  clonic  convulsions. 

4.  Irregular  or  aborted  paroxysms. 

5.  Recent  investigations  have  led  me  to  the  recognition  of  a  dis- 
tinct form  of  epilepsy  characterized  by  hallucinations,  and  to  which  I 
have  ventured  to  propose  the  name  Thalamic  Epilepsy. 

Besides  these  several  varieties,  there  are  certain  accompaniments, 
such  as  hysteria,  mania,  and  paralysis,  which  will  require  consideration. 

1.  Momentary  Unconsciousness  without  Evident  Spasm. — The  pa- 
tient is  perhaps  standing,  engaged  in  conversation,  when  a  momentary 
blank  in  his  mental  processes  occurs.  It  probably  does  not  attract 
attention  ;  it  is  instantaneous,  disappears,  leaving  no  feeling  of  dis- 
comfort after  it,  and  there  is  an  almost  immediate  continuance  of  his 
thoughts  and  speech.  Or  he  may  be  walking  in  the  street  when  the 
accession  occurs.  He  loses  himself  for  an  instant,  but  he  continues  to 
walk,  and  does  not  even  stagger. 

In  somewhat  more  severe  seizures,  if  conversing,  he  stops  sudden- 
ly, stares  vacantly  but  fixedly  for  a  moment,  and  may  drop  anything 
which  he  has  in  his  hand. 

If  walking,  his  steps  are  arrested  for  an  instant,  he  staggers,  and 
would  fall  but  for  the  quick  return  of  consciousness. 

Such  is  the  general  character  of  these  absences,  faints,  spells,  etc., 
as  they  are  popularly  called  ;  varying,  however,  according  to  the  cir- 
cumstances of  the  moment  and  the  condition  of  the  patient.  They  fre- 
quently exist  for  a  long  time  without  the  patient  paying  much  atten- 
tion to  them.  In  a  gentleman  nowr  under  my  charge  they  occurred 
several  times  in  the  course  of  the  day  wThen  walking,  riding  on  horse- 
back, sitting  quietly  in  his  library,  engaged  in  conversation,  or  eating. 
The  continuity  of  his  acts  was  scarcely  interrupted,  and  those  about 
him  never  noticed  that  anything  was  wrong. 

In  the  case  of  a  young  lady  they  occur  generally  at  the  dinner- 
table.  She  drops  her  knife  and  fork,  looks  steadily  to  the  front,  ceases 
to  eat,  and  in  about  two  seconds  resumes  her  occupation  with  a  long- 
drawn  inspiration.  Those  near  her  observe  that  her  countenance  be- 
comes very  pale,  and  that  she  does  not  hear  or  see. 

Sometimes  these  attacks,  slight  as  they  are,  are  followed  by  pain  in 
the  head,  vertigo,  confusion  of  ideas,  numbness,  and  other  evidences  of 
nervous  derangement,  which  may  last  for  several  hours,  and  which  be- 
come more  pronounced  as  the  epileptic  condition  becomes  more  con- 
firmed. 

2.  Unconsciousness,  with  Evident  though  Local  Spasm. — In  this 
variety  the  loss  of  consciousness  is  of  longer  duration  than  in  the  pre- 


EPILEPSY.  669 

ceding,  and  is  attended  with  convulsions  light  in  character,  but  yet  ap- 
parent to  those  around.  The  eyes  are  fixed,  as  in  the  first  variety,  the 
mind  becomes  a  blank,  and  there  is  a  sensation  of  vertigo  immediately 
before  the  loss  of  consciousness,  and  at  the  time  of  its  restoration. 
The  face  usually  becomes  pale  first  and  then  red,  or  either  of  these  con- 
ditions may  occur  without  the  other  being  observed. 

The  spasms  may  be  very  slight.  Sometimes  there  is  momentary 
strabismus,  at  others  retraction  of  the  angles  of  the  mouth  on  one  or 
both  sides,  rotation  of  the  head  or  a  sudden  drawing  of  it  backward,  or 
the  tongue  is  thrust  forward  and  the  jaws  close  on  it,  inflicting  slight 
injury.  Again,  the  chair  in  which  the  patient  may  be  sitting  is  pushed 
back  with  some  force,  and  the  body  is  bent  forward,  or  the  muscles  of 
the  neck  may  be  affected,  and  the  circulation  thus  interrupted  in  the 
veins  of  the  neck,  causing  a  dark  hue  of  the  complexion. 

Sometimes  the  spasms  have  an  appearance  of  being  volitional.  A 
patient  under  my  charge  tugs  violently  at  his  hand  ;  another  walks 
about  the  room,  but  without  taking  any  determinate  course  ;  a  young 
lady  leaves  her  chair  and  stands  upon  another  one  at  some  distance 
from  her,  and  another  talks  all  kinds  of  gibberish.  My  experience  of 
such  cases  is  in  accordance  with  that  of  Reynolds,1  to  the  effect  that 
there  is  no  recollection  of  these  acts.  These  attacks  are  often  preceded 
by  prodromata  of  various  kinds.  The  duration  rarely  exceeds  a  minute, 
and  is  generally  much  less. 

3.  Unconsciousness,  with  General  Tonic  and  Clonic  Convulsions. 
— Prodromata  may  or  may  not  be  present.  In  any  event  the  paroxvsm 
occurs  suddenly.  The  first  circumstance  may  be  a  cry  of  a  very  peculiar 
character,  somewhat  resembling  the  bleating  of  a  young  lamb.  The 
eyes  become  fixed,  and  the  patient  falls  to  the  ground,  usually  with  a 
bound,  as  if  he  is  shot.  The  loss  of  consciousness  occurs  with  the  cry, 
or  with  the  fixedness  of  the  gaze. 

The  muscles  are  now  thrown  into  a  state  of  tonic  contraction  ;  the 
respiration  is  impeded,  or  altogether  arrested  ;  the  face,  if  at  first  pale, 
becomes  dark;  the  pupils  are  dilated,  and  sensibility  is  entirely  abol- 
ished. 

(  an  l':il  examination  of  a  patient  in  this  stage  of  the  paroxysm  re- 
-  some  important  features  :  the  body  is  rigid,  but  is  usually  inclined 
more  to  one  side  than  the  other,  in  the  position  of  a  tetanic  patient 
witli  i >!<-u ro^thotonos  ;  the  eyes  are  open,  and  are  twisted  to  one  side  ; 
tli»:  face  is  Likewise  more  retracted  on  one  side  than  the  other  ;  the 
sterno-cleido-mastoid  muscles,  and  others  of  the  neck,  stand  <>ut  like 
thick  cords  ;  the  carotids  throb  with  i'<>rco.  ;  the  veins  of  the  head  and 
neck  are  turgid  with  black  blood,  and  the  pulse  is  usually  weak  and 
fluttering. 

r  this  stage  has  lasted  for  a  period  varying  from  two  or  three 
1  "System  of  Medicine,"  vol.  ii.,  p.  261,  trtiole  "  Bpile] 


670  CEREBRO-SPJNAL   DISEASES. 

seconds  to  half  a  minute,  a  great  change  ensues.  The  unconsciousness 
continues,  but  the  general  tonic  spasm  relaxes,  and  clonic  convulsions 
take  its  place.  These  are  general,  but  are  ordinarily  more  strongly 
marked  on  one  side  of  the  body  than  on  the  other.  The  muscles  of  the 
face  are  alternately  contracted  and  relaxed  ;  the  tongue  is  often  thrust 
between  the  teeth,  and,  the  jaws  being  closed  upon  it,  it  is  terribly  in- 
jux-ed  ;  the  upper  and  lower  extremities  are  in  a  state  of  continued  agi- 
tation, and  the  contents  of  the  bladder,  rectum,  and  vesicular  seminales, 
may  be  evacuated. 

The  respiration  is  forced  and  irregular,  froth  issues  from  the  mouth, 
and,  if  the  tongue  has  been  bitten,  it  is  colored  with  blood. 

The  muscles  of  the  neck  do  not  relax  to  any  considerable  extent ; 
consequently  the  veins  remain  distended,,  and  the  face  continues  to  bo 
livid.     The  pupils  oscillate,  sometimes  being  dilated  and  then  contract 
ed,  or  one  may  be  contracted  and  the  other  dilated.     The  heart  beats 
with  great  irregularity,  both  as  to  force  and  frequency. 

This  stage  may  last  from  a  few  seconds  to  five  minutes.  Cases  of 
longer  duration  are  on  record,  but  they  are  exceedingly  rare. 

The  third  stage  of  the  paroxysm  is  characterized  by  the  gradual 
return  of  consciousness.  The  patient,  though  still  somewhat  convulsed, 
looks  around  him,  and  gives  evidence  of  returning  sensibility  in  other 
ways.  The  pupils  cease  their  disorderly  movements,  and  are  contracted ; 
the  respiration  and  pulse  become  more  regular,  and  he  may  even  attempt 
to  speak.  It  often  happens  that  little  spots  of  extra vasated  blood  make 
their  appearance  under  the  skin  of  the  forehead,  eyelids,  cheeks,  and 
sometimes  on  the  neck  and  breast.     These  disappear  in  a  few  days. 

The  duration  of  this  stage  is  from  a  few  seconds  to  four  or  five 
minutes,  and  it  is  often  so  slightly  marked  as  to  escape  observation. 

With  the  cessation  of  the  convulsive  movements  the  stage  of  stupor 
usually  supervenes,  though  it  may  be  entirely  absent,  especially  in  old 
cases  of  epilepsy.  During  this  stage  there  are  sometimes  clonic  spasms 
of  no  great  degree  of  severity.  It  may  last  a  few  minutes  or  several 
hours.  When  the  patient  arouses  from  it,  he  generally  has  headache, 
and  a  feeling  of  lassitude  and  soreness  of  the  muscles,  from  the  violent 
contractions  they  have  undergone. 

4.  Irregular  or  Aborted  Paroxysms. — In  these  it  may  happen  that 
the  loss  of  consciousness  is  not  complete,  or  that  the  patient  has  con- 
vulsive movements  partial  in  character  and  accompanied  simply  by  ver- 
tigo, or  he  may  have  unconsciousness  lasting  for  an  hour  or  more, 
during  which  he  performs  automatic  acts,  of  which  he  has  no  recollec- 
tion, but  which  are  not  accompanied  by  any  movements  that  can  prop- 
erly be  called  spasmodic. 

In  his  interesting  lecture  on  "  Apoplectiform  Cerebral  Congestion," 
Trousseau  '  cites  a  number  of  cases  which  were  clearly  instances  of 
1  Op.  cit.,  Bazire's  translation,  pp.  19,  et  teq. 


EPILEPST.  671 

irregular  or  abortive  epileptic  paroxysms.  Among  them  is  that  of  a 
magistrate  whose  sister  was  an  inmate  of  a  lunatic  asylum.  He  was 
president  of  a  provincial  tribunal.  One  day  he  got  up  all  of  a  sudden, 
muttered  a  few  unintelligible  words,  and  went  to  the  deliberating-room. 
The  usher  followed  him,  and  saw  him  make  water  in  a  corner.  A  few 
minutes  afterward  he  returned  to  his  seat,  and  again  listened  with  in- 
telligence and  attention  to  the  pleadings  momentarily  interrupted.  He 
had  no  recollection  of  the  incredibly  incongruous  act  he  had  committed. 
This  gentleman  belonged  to  a  literary  society,  which  held  its  meetings 
at  the  H6tel-de-Ville,  of  Paris.  At  one  of  these,  during  the  discussion 
of  an  important  historical  point,  he  was  seized  with  vertigo.  He  ran 
quickly  down  to  the  Place  de  H6tel-de-Ville,  and  walked  about  for  a 
few  minutes  on  the  quays,  avoiding  with  success  both  carriages  and  the 
passers-by.  On  recovering  himself  he  perceived  that  he  had  come  out 
without  his  great-coat  and  his  hat.  He  therefore  returned  to  the  meet- 
ing, and  resumed  with  a  perfectly  lucid  mind  the  historical  discussion  in 
which  he  had  already  taken  a  very  active  part.  He  retained  no  recol- 
lection whatever  of  what  had  occurred  between  the  beginning  of  the 
attack  and  the  moment  he  recovered  himself. 

Many  cases  similar  to  these  might  be  cited  from  other  authors. 
From  a  number  which  have  happened  in  my  own  experience  I  adduce 
the  following: 

J.  H.  consulted  me  for  epilepsy  in  the  summer  of  1869.  His  ordi- 
nary attacks  were  of  the  fully-developed  form;  but  upon  two  occasions 
they  were  different  from  any  with  which  he  had  previously  been  af- 
fected. On  one  of  these,  while  overlooking  some  workmen,  he  was 
observed  to  put  his  hand  to  his  head,  and  then  sudddenly  to  run  toward 
a  fence,  which  he  speedily  climbed.  Jumping  down  into  the  back-yard 
of  the  adjoining  house,  he  seized  a  stick  of  wood  near  by,  and  made  a 
furious  onslaught  on  the  door  and  windows.  "While  thus  engaged  he 
was  seized  by  several  men,  and  forcibly  held,  notwithstanding  his  strug- 
gles. While  thus  being  restrained  he  recovered  his  consciousness,  but 
had  no  recollection  of  any  thing  which  had  taken  place  after  he  had  put 
his  hand  to  his  head,  which  action  he  said  was  due  to  severe  pain  with 
vertigo.     The  duration  of  the  attack  was  not  over  three  minutes. 

On  tin-  other  occasion  he  was  seized  with  pain  and  vertigo  while 
engaged  in  paying  a  bill  at  a  coal-yard.  He  rushed  into  the  street, 
and  began  to  turn  rapidly  round.  He  was  seized  and  held  till  he  re- 
covered his  consciousness.     This  attack  lasted  about  four  minutes. 

Subsequently  he  had  a  similar  paroxysm  in  my  consulting-room. 
His  lace  suddenly  became  very  pale,  liis  dyes  were  fixed,  and  liis  pupils 
oscillated.  Suddenly  he  rose  from  the  chair,  grasped  the  mantel-pieoe 
for  an  instant,  and  then  rushed  violently  around  the  room,  throwing  his 
arms  about,  and  uttering  a  peculiar  inarticulate  ory.  1  made  no  at- 
tempt to  restrain  him,  and  in  about  two  minutes  he  became  calm. 


672  CEREBROSPINAL   DISEASES. 

During  the  whole  paroxysm  his  face  was  pale,  and  at  its  close  the  pu- 
pils were  dilated.  He  had  no  recollection  of  any  thing  which  had  oc- 
curred after  he  rose  from  the  chair,  but  was  conscious  then  of  vertigo. 

Another  case  is  that  of  a  girl  brought  to  my  clinic  at  the  Bellevue 
Hospital  Medical  College  during  the  summer  of  18G9.  She  had  been 
severely  injured  in  the  skull  by  a  fall  against  a  mass  of  old  iron.  Ne- 
crosis subsequently  ensued,  and  several  large  pieces  of  the  external 
table  were  exfoliated.  While  before  the  class,  she  started  to  her  feet, 
and  walked  several  times  around  the  closed  area.  She  was  unconscious, 
and  to  all  appearance  insensible.  When  the  paroxysm  was  over  she 
returned  to  her  seat.  The  duration  did  not  exceed  a  minute,  and  there 
was  no  excitement  or  delirium. 

Another  patient,  a  partner  in  an  extensive  mercantile  establish- 
ment, who  was  subject  to  attacks  of  both  the  grand,  and  petit  mal}  left 
his  office  at  about  eleven  o'clock  for  the  purpose  of  getting  a  signature 
to  a  paper  of  some  kind  from  a  gentleman  whose  place  of  business  was 
a  few  minutes'  walk  distant.  Not  returning  by  three  o'clock,  inquiry 
was  made,  and  it  was  ascertained  that  he  had  visited  the  office,  obtained 
the  signature,  and  had  left  in  apparently  good  health  before  half-past 
eleven.  Since  then  nothing  had  been  heard  of  him.  He  did  not  make 
his  appearance  at  his  own  office  till  nearly  five  o'clock. 

The  last  thing  he  recollected  was  passing  St.  Paul's  Church  at  the 
corner  of  Broadway  and  Vesey  Street,  just  as  the  congregation  was 
coming  out  after  morning  service.  It  was  subsequently  ascertained 
that  he  had  gone  to  Brooklyn  after  getting  the  signature  he  wanted, 
had  visited  a  newspaper-office  and  purchased  a  paper  ;  had  returned  to 
New  York,  entered  an  omnibus  at  the  Fulton  Ferry,  left  it  at  the  corner 
of  Twenty-third  Street  and  Fifth  Avenue,  entered  the  Fifth  Avenue 
Hotel,  and  while  there  recovered  his  recollection. 

But  none  of  these  cases,  nor  any  of  which  I  have  seen  any  report, 
are  equal  in  interest  to  one  which  occurred  in  my  practice  during  the 
autumn  of  1875.  The  patient,  who  was  engaged  in  active  business  as  a 
manufacturer,  left  his  office  at  about  9  A.  M.,  saying  he  was  going  to  a 
florist's  to  purchase  some  bulbs.  He  remained  absent  eight  days.  He 
was  tracked  all  over  the  city,  but  the  detectives  and  friends  were  always 
an  hour  or  more  behind  him.  It  was  ascertained  that  he  had  been  to 
theatres,  to  hotels,  where  he  slept,  to  shops  where  he  had  made  pur- 
chases, and  that  he  had  made  a  journey  of  a  hundred  miles  from  New 
York,  and,  losing  his  ticket  and  not  being  able  to  give  a  satisfactory 
account  of  himself,  was  put  off  of  the  train  at  a  way-station.  He  had 
then  returned  to  New  York,  passed  the  night  at  an  hotel,  and  on  the 
eighth  day,  at  about  ten  o'clock,  made  his  appearance  at  his  office.  He 
had  no  recollection  of  any  one  event  which  had  taken  place  after  leav- 
ing his  place  of  business,  eight  days  previously,  till  he  awo.ke  on  the 
morning  after  his  return  to  the  city,  and  found  himself  in  an  hotel  at 


EPILEPSY.  673 

which  he  was  a  stranger.  It  was  ascertained  beyond  question  that  in 
all  this  time  his  actions  had  been  entirely  correct  to  all  appearance,  that 
his  speech  was  coherent,  and  that  he  had  acted  entirely  in  all  respects 
as  any  man  in  the  full  possession  of  his  mental  faculties  would  have 
acted.  He  had  drunk  nothing  but  a  glass  of  ale,  which  he  took  with 
some  oysters  at  a  restaurant  in  Sixth  Avenue. 

It  could  not  be  ascertained  that  this  patient  had  ever  had  an  epilep- 
tic paroxysm  ;  but  he  had  a  year  previously  been  under  my  charge  for 
cerebral  symptoms,  indicating  the  existence  of  chronic  basilar  menin- 
gitis, and  only  a  week  before  his  disappearance  I  had  discharged  him 
cured,  after  a  month's  treatment  for  severe  pain  in  the  head,  dizziness, 
paralysis  of  the  third  nerve  on  the  right  side,  and  extreme  insomnia. 
There  were  all  the  indications  of  specific  cause,  and  I  had  treated  him 
with  large  doses  of  the  iodide  of  potassium,  as  on  the  former  occasion. 

Most,  if  net  all,  of  the  cases  of  "  double  consciousness  "  that  have 
been  reported  are  doubtless  epileptic  in  character.  An  interesting  case 
of  the  kind  has  been  related  by  M.  Azam.1  It  is  that  of  a  young  woman 
who,  after  having  suffered  from  hysteria  and  convulsions,  had  two  dis- 
tinct phases  of  existence,  living,  in  fact,  two  separate  and  different  lives, 
and  exhibiting  different  likes  and  dislikes  and  mental  characteristics. 

Another  case  was  that  of  a  sergeant,  reported  by  Dr.  Mesnet/  who, 
after  receiving  a  severe  wound  of  the  skull,  had  paroxysms  charac- 
terized by  total  change  in  his  mentality,  and  obliviousness  of  all  acts 
performed  in  his  normal  state.  During  these  periods  he  was  con- 
scious, and  acted  in  a  logical  and  coherent  manner. 

5.  Unconsciousness  with  Hallucinations. — In  this  form  of  epilepsy, 
which  I  described  in  a  paper  read  before  the  American  Neurological  As- 
sociation, June  18, 1880,3  the  characteristics  are  conscious  hallucinations, 
followed  by  unconsciousness  but  unattended  by  muscular  spasm.  I  have 
had  the  opportunity  of  seeing  two  eases  (one  since  the  reading  of  the 
paper)  while  the  paroxysms  were  present,  and  in  neither  was  there  the 
hast  spasmodic  action.  I  quote  part  of  the  description  of  one  of  the 
.  thai  of  a  young  woman  on  which  the  memoir  in  question  is  based  : 

"  I  had  the  opportunity  of  witnessing  seventeen  paroxysms.  Some- 
times they  were  preceded  by  a  well-marked  aura,  and  this  was  always 
a  sensation  apparently  somewhere  within  the  cranium,  hut  not  capable 
of  being  exactly  localized  or  described.  This  was  never  felt  until 
within  the  last  two  years.  It  lasted  only  a  second  or  two,  and  was  im- 
mediately fallow  ed  by  the  '  \  Lsion.' 

1  "Amnesle  p£riodique,  ou  d6doublemenf  dc  la  vie,"  Annates  M&dico-psycl 
July,  I 

-  Union   tfSdicale,  Jul;,    'jl   and  28,  1874.     Translated  in  1  ha  Chicago  Journal  for 
Kervow  and  3ft «/"/  Disease,  January,  1875. 

8  "On  Thalamic  Epilepsy,"  Archives  of  Scientific  Medicine^  August,  L880.    Also,  Xruro- 
(ot/ical  Contributions,  No.  Ill  ,  1881. 
44 


674  CEREBRO-SPINAL   DISEASES. 

"The  first  paroxysm  of  this  series  which  I  witnessed  was  ushered 
in  by  the  aura.  She  had  hardly  time  to  say, '  It's  coming,'  when  the 
hallucination  began.  She  described  it  as  consisting  of  a  large  white 
bear  in  motion  before  her  on  the  carpet.  It  seemed  to  be  walking 
slowly  to  and  fro,  its  head  bent  toward  the  floor  as  if  scenting  some- 
thing. I  closely  watched  her,  and  could  detect  no  spasm  anywhere. 
She  spoke  clearly,  without  hesitation,  and  with  entire  distinctness. 
The  pupils  were  normal. 

"I  had  taken  out  my  watch  to  time  the  duration  of  the  attack. 
Thirty-five  seconds  elapsed,  and  then  her  pupils  suddenly  dilated,  her 
head  fell  forward,  and  her  left  hand,  which  was  at  this  instant  pointing 
in  the  direction  of  the  visional  bear,  dropped  to  her  side.  I  pinched 
the  skin  of  her  face,  then  of  each  hand,  without  eliciting  any  evidence 
of  cutaneous  sensibility.  I  took  up  a  fold  of  skin  on  each  forearm 
just  above  the  wrist  and  stuck  a  cataract-needle,  which  was  at  hand, 
through  it,  with  a  like  result.  Her  pulse — I  had  not  felt  it  during  the 
existence  of  the  hallucination — was  beating  at  the  rate  of  about  sixty 
a  minute,  and  was  full.  Her  face  had  not  altered  in  color,  nor  was 
there  any  other  change  in  it  except  such  as  was  due  to  relaxation  of 
the  muscles — such  as  is  present  in  sleep.  The  eyelids  were  closed,  but 
not  spasmodically.  She  remained  in  this  state  exactly  twenty-eight 
seconds,  breathing  perhaps  a  little  more  slowly  and  deeply  than  before 
the  accession  of  the  paroxysm.  Suddenly  she  raised  her  head,  looked 
inquiringly  around  her  for  a  moment,  and  then,  as  if  becoming  aware 
of  a  sensation,  looked  at  both  her  arms  where  I  had  pricked  them.  A 
drop  of  blood  was  oozing  from  each  puncture.  She  asked  what  it  was, 
and  then,  without  waiting  for  an  answer,  exclaimed,  'You  have  bled 
me  ! '  She  was  then  entirely  herself,  and  talked  coherently,  and  without 
the  least  excitement,  about  the  hallucination. 

"  While  making  memoranda  of  the  phenomena  I  had  observed,  and 
while  she  was  walking  up  and  down  the  floor,  she  said  that  she  was 
going  to  have  another  attack,  as  she  felt  the  peculiar  sensation  again 
in  her  head.  She  had  no  sooner  uttered  the  words  than  the  vision 
came.  '  It's  a  girl  this  time  ! '  she  exclaimed — '  a  girl  with  long  auburn 
hair,  and  a  cap  on  her  head  ;  she  looks  like  a  French  nurse.  I  think  I 
will  sit  down,  for*  if  I  do  not  I  shall  fall  as  soon  as  I  become  insen- 
sible ;'  saying  which,  she  quietly  sat  down  in  a  large  arm-chair. 

"I  pinched  the  skin  of  her  right  hand.  'Oh  ! '  she  exclaimed,  'I 
feel  that ;  I  am  not  insensible  yet  ;  I  see  everything  in  the  room  as 
well  as  I  do  the  girl  who  is  not  here.  I  can  feel  the  least  touch,  and 
my  hearing  is  as  good  as  ever.' 

"  I  asked  her  what '  the  girl '  was  doing.  '  Oh,  nothing,'  she  replied  ; 
'  she  is  only  standing  there  in  front  of  the  fireplace,  looking  at  me.' 

"  I  told  her  to  shut  her  eyes,  and  then  to  tell  me  if  she  still  saw 
1  the  girl.' 


EPILEPSY.  675 

"'Yes,'  she  answered,  'just  as  distinctly  as  I  did  when  they  were 
open.' 

"At  forty-one  seconds  she  became  unconscious,  and  remained 
in  this  state  for  one  minute  and  five  seconds,  awaking — I  say  awak- 
ing, for  her  appearance  was  like  that  of  a  person  asleep — sudden- 
ly, and  apparently  in  a  normal  condition  of  mental  and  physical 
health." 

Subsequently,  from  inattention  to  treatment  on  the  part  of  the  pa- 
tient, the  paroxysms  passed  into  others  with  strong  muscular  contrac- 
tions, and  she  exhibited  indications  of  a  tendency  to  the  perpetration 
of  acts  of  violence. 

In  all,  six  cases  of  this  interesting  form  of  epilepsy  have  come 
under  my  observation  ;  and  I  have  learned  of  others  being  recognized 
by  several  physicians  of  competent  powers  of  observation. 

Relative  to  the  mental  disturbance  which  sometimes  ensues  upon  epi- 
leptic paroxysms,  Dr.  Hughlings  Jackson '  has  recently  given  some  inter- 
esting details  relative  to  acts  performed  by  epileptics  during  periods  of 
unconsciousness.  In  his  opinion  such  acts  are  automatic,  not — to  speak 
exactly — epileptic,  but  post-epileptic.  "  The  condition  after  the  parox- 
ysm is  duplex  :  (1)  there  is  loss  or  defect  of  consciousness,  and  there  is 
(2)  mental  automatism.  In  other  words,  there  is  (1)  loss  of  control, 
permitting  (2)  increased  automatic  action."  The  epileptic  seizure  may 
be  so  slight  and  transitory  as  to  escape  observation,  but  the  slighter  it 
is  the  more  apt  is  the  resulting  automatism  to  be  complex  and  elab- 
orate. 

Dr.  Jackson  gives  a  number  of  exceedingly  interesting  cases  in  illus- 
tration of  his  views,  which  in  addition  are  enforced  with  much  cogent 
reasoning.  But,  while  in  the  main  agreeing  with  him,  I  am  scarcely 
prepared  to  deny  that  such  unconscious  attacks  may  not  be  substituted 
for  the  more  fully-developed  paroxysm  instead  of,  as  in  his  opinion, 
always  following  a  seizure. 

Epileptic  fits  may  take  place  at  night  during  sleep,  and  the  patient 
be  unaware  of  their  existence,  unless  he  inflicts  some  injury  on  himself, 
such  as  biting  his  tongue,  or  is  told  of  their  occurrence  by  persons  who 
may  be  in  the  same  room  with  him.  In  two  hundred  and  six  of  my 
cases  the  period  of  access  is  noted,  and,  of  these,  forty-seven  were  noc- 
turnal, and  one  hundred  and  fifty-nine  diurnal. 

In  the  intervals  between  the  paroxysms  epileptics  often  exhibit  cer- 
tain evidences  of  disordered  mental,  sensorial,  and  motor  functions, 
Thus,  as  regards  the  first  category,  the  memory  may  be  impaired,  and 
there  may  1"-  diminished  mental  power.  There  are,  however,  many 
exceptions  to  this  rul<-;  ami,  even  where  there  have  been  a  greal  many 
attacks,  the  mind  may  preserve  its  normal  degree  of  integrity.     As 

•  "On  Temporary  Mental  Disorders  after  Epileptic  Paroxysms,"  "West  Riding  Lu- 
natic Asylum  Medical  Reports,"  vol.  v.,  p.  105. 


676  CEREBRO-SPINAL   DISEASES. 

Reynolds  remarks,  in  regard  to  this  point:  "  A  patient  may  be  epileptic 
and  a  lunatic;  he  may  be  epileptic  and  asthmatic,  but  there  are  some 
epileptics  whose  minds  are  as  healthy  as  their  lungs;  and,  so  far  as  the 
natural  history  of  epilepsy  is  concerned,  it  is  a  mistake  to  derive  it  from 
complicated  cases."  Still,  in  the  majority  of  cases,  it  will  be  found  that 
the  mind  sooner  or  later  becomes  involved,  and  it  sometimes  happens 
that  a  single  attack  causes  marked  intellectual  deterioration. 

Derangements  of  sensibility  are  common  from  the  beginning. 
Headache,  a  feeling  of  constriction  around  the  forehead,  and  occasion- 
ally a  pain  at  the  back  of  the  head,  are  noticed.  Vertigo  is  also  fre- 
quently present,  as  are  also  sensations  of  numbness  in  different  parts  of 
the  body.     The  pupils  are  almost  invariably  dilated. 

The  motor  power  of  the  patient  is  generally  weakened  without  there 
being  any  decided  paralysis.  Twitchings  of  the  muscles  are  not  un- 
common, and  there  is  often  a  general  excitability  of  the  reflex  faculty 
of  the  spinal  cord,  by  which  jerkings  of  the  limbs  are  produced  by 
slight  excitations. 

The  circulation  is  generally  sluggish,  the  extremities  are  cold,  and 
the  capillaries  are  turgid  and  inactive,  so  that,  if  the  finger  be  pressed 
firmly  upon  the  skin,  a  considerable  period  elapses  before  the  white  spot 
disappears  by  the  refilling  of  the  vessels. 

In  examining  with  the  ophthalmoscope  the  fundus  of  the  eye  in 
epileptics,  we  can  often  detect  evidences  either  of  cerebral  congestion 
or  of  anaemia,  and  thus  obtain  valuable  indications  for  treatment.  For 
several  years,  in  my  lectures,  I  have  constantly  insisted  on  this  point, 
and  in  my  cliniques  have  exhibited  several  cases  in  which  I  had  been 
guided  to  successful  treatment  by  the  ophthalmoscope.  Drs.  Kostle  and 
Niemetshek,1  of  Prague,  consider  that  the  brain  in  epileptics  is  always 
anaemic,  and  that  this  condition  is  invariably  found  by  ophthalmoscopic 
examination.  According  to  these  observers,  the  venous  pulse  is  pro- 
duced when  the  eye  is  made  anaemic,  and  they  assert  that  the  retina  is 
anaemic,  and  that  there  is  consequently  venous  pulsation  in  every  case 
of  epilepsy.  That  this  opinion  is  erroneous,  both  as  to  the  facts  and 
inferences,  I  am  very  sure.  Venous  pulsation,  so  far  from  being  indica- 
tive of  anaemia,  really  shows  the  existence  of  the  very  opposite  con- 
dition. My  observations  are,  however,  to  the  effect  that  venous  pul- 
sation is  present  in  many  cases  of  epilepsy,  and  that  it  accompanies 
dilatation  of  the  veins. 

There  is  no  invariable  rule  relative  to  the  occurrence  of  any  par- 
ticular form  of  epilepsy  in  the  same  person.  It  thus  often  happens 
that  all  the  varieties  of  paroxysm  mentioned,  except  the  irregular  or 
aborted  form,  which  is  more  rare,  are  met  with  in  one  individual.  The 
more  severe  forms  may  occur  at  longer  intervals,  and  the  milder  forms 

1  Pmger  Vierleljahrschrift,  H.  106,  107,  1870,  and  Quarterly  Journal  of  Psychological 
Medicine,  January  1871,  p.  128. 


EPILEPSY.  677 

more  frequently.  As  regards  frequency,  there  are  great  variations. 
Some  patients  go  a  year  or  more  without  attacks,  while  others  have 
several  every  day.  It  generally  happens  that  the  intervals  become 
progressively  shorter.  As  a  rule,  attacks  of  the  milder  forms  are  more 
frequent  than  the  fully-developed  paroxysm,  and  attacks  of  the  latter 
are  milder,  as  they  are  more  frequent. 

Mania  is  sometimes  a  consequence  of  epilepsy.  It  comes  on  after 
the  attack,  and  is  rarely  of  more  than  a  few  minutes'  duration.  Those 
cases  in  which  it  precedes  the  paroxysm,  and  lasts  several  hours  or 
days,  are  cases  of  mania  conjoined  with  epilepsy — a  combination  which, 
as  every  insane  asylum  shows,  is  not  uncommon.  The  mania  of  epi- 
lepsy is  usually  of  a  very  exalted  character,  and  during  its  existence 
the  subject  may  commit  homicide  or  other  crimes. 

The  mental  state  of  epilepsy  has  been  well  studied  by  Falret,1  and 
a  very  interesting  case  has  been  recently  reported  by  Dr.  Thorne,4  in  a 
paper  entitled  "  Masked  Epilepsy."  In  this  instance  the  patient  often 
returned  to  his  home  without  being  able  to  give  any  account  of  what 
he  had  been  doing  or  where  he  had  been.  During  these  attacks  he  was 
frequently  the  subject  of  that  form  of  mental  derangement  called  klep- 
tomania. Generally  they  ensued  on  paroxysms  either  of  the  grand  or 
petit  mal,  but  sometimes  they  were  substituted  for  the  regular  seiz- 
ures. He  had  no  recollection  of  what  occurred  during  the  attacks. 
Sometimes  he  was  furiously  excited  in  them,  and  would  endeavor  to 
injure  himself  and  others  in  his  blind  rage. 

Relative  to  the  diagnosis  of  the  remarkable  paroxysms,  the  main 
feature  of  which  is  unconsciousness,  or  rather  non-recollection  of 
consciousness,  in  which  the  individual  acts  apparently  automatically, 
great  difficulties  exist.  Probably  nothing  short  of  a  full  history  of  the 
case,  from  infancy  up,  will  suffice  for  the  recognition  of  the  real  nature 
of  the  phenomena.  There  appears  to  be  an  idea  in  the  minds  of  some 
physicians,  that  every  outrageous  criminal  act  is  the  result  of  epilepsy, 
and  so  wide-spread  is  this  notion,  that  now  the  first  plea  of  the  murderer 
is,  that  he  "knew  nothing  about  it  ;  "  and  the  fact  that  an  individual 
who  has  perpetrated  a  murderous  outrage  \s  the  subject  from  time  to 
time  of  epileptic  seizures,  is  regarded  as  sufficient  to  absolve  him  from 
all  responsibility  for  his  actions.  The  fact  of  a  discolored  spot  on  his 
pillow,  or  of  an  infantile  convulsion,  is  seized  upon  as  a  valid  reason 
for  acquittal,  or  even  for  setting  aside  a  verdict  found  after  a  full  and 
fair  trial.  In  the  first  place,  it  must  be  understood  that  an  undoubted 
epileptic  is  just  as  capable  of  murdering  for  revenge  or  gain  as  is  a 
healthy  person,  and  that  he  is  just  as  accountable,  and  should  accord- 
ingly suffer  the  full  penalty  of  the  law  for  his  conduct.     At  the  same 

1  "  De  lY>tat  mental  dea  epileptiques,"  Archives  genirales  de  medecine,  Ddcembre,  1860, 
et  Avril  et  Octobrc,  1861. 

•  "St.  Bartholomew's  Hospital  Reports,"  1870. 


678  CEREBROSPINAL  DISEASES. 

time,  it  is  not  to  be  questioned  that  acts  of  violence  may  be  perpetrated 
during  seizures  which  are  either  epileptic  or  the  direct  consequence  of 
an  epileptic  paroxysm.  It  is  only  by  the  most  thorough  and  careful 
inquiry  into  all  the  motives  for  and  circumstances  attending  upon  the 
act,  as  well  as  all  the  antecedents  of  the  individual,  that  a  proper 
discrimination  can  be  made.  Each  case  must  be  determined  for  itself  ; 
there  are  no  rules  applicable  invariably  to  all. 

The  medico-legal  relations  of  epilepsy  do  not,  however,  come  with- 
in the  scope  of  the  present  treatise. 

Paralysis  may  follow  epilepsy,  but,  unless  the  case  is  complicated 
with  some  organic  disease  of  the  brain  or  spinal  cord,  the  loss  of 
power  is  temporary. 

Causes. — Among  the  predisposing  causes  of  epilepsy,  hereditary 
tendency  stands  first.  Reynolds  '  states  that,  in  about  one-third  of  the 
cases  under  his  observation,  hereditary  taint  existed.  He  does  not,  by 
this  statement,  however,  mean  to  assert  that  epilepsy  existed  in  one- 
third  of  the  parents,  but  that  some  disease  of  the  nervous  system, 
more  or  less  closely  allied  to  epilepsy,  was  present  in  either  the  parents, 
the  grandparents,  the  aunts,  uncles,  brothers,  or  sisters.  Only  twelve 
per  cent,  of  his  cases  gave  a  distinct  history  of  epilepsy  in  either 
branch  of  their  families. 

Herpin,a  of  sixty-eight  cases,  found  that  ten  were  descended  from 
epileptic  ancestors. 

Delasiauve,3  of  three  hundred  cases,  found  decided  evidence  of 
hereditary  tendency  in  thirty-three.  In  one  hundred  and  sixty-seven 
there  were  no  data,  and  in  one  hundred  and  twenty  hereditary  taint 
was  denied.  Of  the  thirty-three  cases,  five  were  descended  from  epi- 
leptic ancestors. 

Sieveking  *  found  that  hereditary  influence  was  present  in  11.1  per 
cent,  of  his  cases. 

In  my  own  experience  I  have  notes  in  regard  to  this  point  in  three 
hundred  and  ninety-six  cases.  Of  these,  sixty-four  had  epileptic  fa- 
thers, mothers,  grandparents,  uncles,  aunts,  brothers,  or  sisters,  and 
forty-eight  had  relatives  insane,  hysterical,  cataleptic,  affected  with 
severe  neuralgia,  or  of  remarkably  irritable  nervous  systems. 

Sex  does  not  appear  to  exercise  any  appreciable  influence  as  a  pre- 
disposing cause.  Of  five  hundred  and  seventy-two  cases  noted  by  my- 
self, two  hundred  and  ninety-eight  were  in  males  and  two  hundred  and 
seventy-four  in  females.  Other  authors  have,  however,  had  directly 
opposite  experience. 

Age  has  a  very  decided  influence.  Reynolds  gives  the  following 
table  of  one  hundred  and  seventy-two  cases  collected  by  himself  : 

1  Op.  cit.,  p.  253. 

9  "  Du  pronostic  et  du  traitement  curatif  de  l'^pilepsie,"  Paris,  1852,  p.  325. 

8  Op.  cit.,  p.  189.  *  «  On  Epilepsy,"  etc.,  London,  1858,  p.  74. 


EPILEPSY. 


679 


Age  at  Commencement. 


Males.     |  Females. 


TotaL 


Under  10  years 

Between  10  and  20  years.. 
Between  20  and  44  years. 
Over  45  years 


Total. 


10 


26 

1 


102 


40 
20 

1 


70 


19 

106 

45 

2 


172 


My  own  cases  were  as  follows 


Age  at  Commencement. 


Under  10  years 

Between  10  and  2U  years 
Between  20  and  45  years 
Over  45  years 

Total 


Males. 


31 

178 
72 
17 


298 


Females. 


29 

151 

71 

23 


274 


TotaL 


60 
329 
143 

40 


572 


It  is  thus  seen  that  the  period  of  life  between  ten  and  twenty  years 
is  that  at  which  epilepsy  is  most  apt  to  occur.  The  experience  of  oth- 
ers is  to  the  same  effect.  The  influence  of  temperament  has  been 
thought  important  by  some  writers.  But,  aside  from  the  different 
opinions  entertained  relative  to  the  characteristics  of  the  temperaments, 
it  is  by  no  means  established  that,  even  when  strictly  defined,  tempera- 
ment exercises  any  effect  as  a  predisposing  cause.  I  have  no  accurate 
records  on  this  point,  though  so  far  as  my  memory  serves  me  I  have 
observed  no  marked  predominance  of  epileptics  with  any  temperament. 

The  exciting  causes  may  very  properly  be  classified  as  psychical, 
eccentric,  general  organic  changes,  and  physical  influences.  Relative 
to  the  influences  of  these  causes,  Reynolds  gives  the  following  table  : 

Nature  of  Cause.  No.  of  Cases. 

I.  Psychical — such  as  fright,  grief,  worry,  overwork 29 

LT.  Eccentric  irritation — dentition,  indigestion,  venereal  excesses,  dys- 
entery, etc 16 

III.  General  organic  changes — fatigue,  pregnancy,  miscarriages,  rheu- 

matic fever,  scarlet  fever,  diphtheria,  pneumonia 9 

IV.  Physical  influences — blows  on  head,  falls,  insolation,  cuts 9 

In  my  own  cases  no  exciting  cause  could  be  assigned  in  one  hun- 
dr<  1  and  seventy-seven.  The  remaining  three  hundred  and  ninety-five 
cases  were,  according  to  the  evidence  received,  caused  as  follows  : 

Fright 35 

Anxiety 17 

f 30 

Over  mental  exertion 48 

Dentition 21 

Indigestion 88 

Carried  forward 184 


680  CEREBROSPINAL  DISEASES. 

Brought  forward 184 

Venereal  and  sexual  excesses 60 

Menstrtial  derangement ' 56 

Blows  on  the  head 24 

Peripheral  wounds  and  iujuries 4 

Falls 13 

Sunstroke 1*7 

Scarlet  fever 3 

Measles 3 

Diphtheria 9 

Pregnancy 3 

Syphilis 13 

Malaria 6 

395 

Diagnosis. — The  diagnosis  of  epilepsy  presents  no  difficulties  to  the 
careful  observer.  It  may,  however,  be  confounded  with  several  condi- 
tions, the  principal  of  which  are  cerebral  congestion,  cerebral  haemor- 
rhage, hysteria,  the  convulsions  of  infancy  and  of  Bright's  disease, 
poisoning  by  opium  and  alcohol,  syncope,  and  with  the  convulsions  of 
epileptiform  character  which  occur  in  the  course  of  certain  organic  dis- 
eases of  the  brain. 

The  diagnosis  from  cerebral  congestion  and  cerebral  haemorrhage 
has  already  been  given  in  the  chapters  treating  of  those  affections.  In 
hysteria,  the  convulsions,  which  are  sometimes  epileptiform  in  charac- 
ter, are  preceded  or  accompanied  by  other  evidences  of  the  hysterical 
state.  Consciousness  is  rarely  entirely  lost,  the  tongue  is  not  bitten, 
and  there  is  no  subsequent  stage  of  stupor. 

The  convulsions  of  infancy  not  epileptic  are  not  repeated  but  from 
a  readily-ascertained  exciting  cause,  such  as  dentition,  indigestion,  falls, 
etc.  So  far  as  the  paroxysm  is  concerned,  I  know  of  no  specific  points 
of  difference;  but  it  must  be  recollected  that  the  paroxysm  is  not  the 
only  feature  of  epilepsy,  and  that  it  is  the  only  feature  of  infantile  con- 
vulsions. These  latter  may  pass  into  epilepsy ;  but,  if  they  do  not,  I 
have  never  been  able  to  find  a  single  case  in  my  experienoe  :ji  which 
epilepsy  ensuing  in  adult  life  has  been  preceded  by  the  ordinary  infan- 
tile convulsions.  In  Bright's  disease,  though  the  convulsions  may  be 
epileptiform  in  character,  coma  is  the  principal  feature,  and  the  history 
of  the  case  will  further  serve  to  render  the  diagnosis  exact.  The  same 
remarks  are  applicable  to  poisoning  by  opium  and  alcohol. 

From  syncope  epilepsy  is  distinguished  by  the  facts  that  the  loss  of 
consciousness  is  sudden  and  complete,  that  the  pulse  is  not  feeble,  and 
that  recovery  is  rapid.  These  remarks  apply  to  the  milder  attacks  with- 
out convulsions.  From  the  more  severe  forms  of  the  paroxysm  the  dis- 
tinction is  too  obvious  to  require  amplification. 

In  organic  diseases  of  the  brain,  such  as  tumors,  softening,  sclerosis, 
etc.,  the  accompanying  symptoms,  pain,  paralysis,  tremor,  imbecility, 


EPILEPSY.  681 

difficulties  of  speech,  and  derangements  of  the  special  senses,  will  serve 
to  distinguish  them  from  epilepsy. 

Epilepsy  is  often  assumed  by  designing  persons  for  purposes  of 
fraud.  In  such  cases  the  pretender  usually  overacts  his  part  ;  his 
sensibility  is  not  abolished,  as  may  readily  be  ascertained  by  putting 
the  end  of  the  finger  on  the  conjunctiva,  and  the  size  of  the  pupils  is 
not  altered. 

Prognosis. — The  prognosis  depends  to  a  great  extent  on  the  dura- 
tion of  the  disease.  Recent  cases  can  often  be  cured,  but  those  which 
have  lasted  for  several  years  are  rarely  brought  to  a  favorable  termina- 
tion. Among  the  other  unfavorable  elements  are  the  existence  of 
hereditary  influence,  the  beginning  of  the  disease  late  in  life,  the  pres- 
ence of  material  mental  weakness,  and  the  existence  of  long  intervals 
between  the  attacks. 

As  regards  the  probability  of  the  supervention  of  any  form  of  in- 
tellectual derangement  or  debility,  the  most  important  ascertained 
point  is  that  the  mild  paroxysms  unattended  by  convulsions  are  more 
productive  of  mental  decay  than  the  severe  form  of  seizure.  The  oc- 
currence of  the  first  attack  late  in  life  is  likewise  a  predisponent  to 
dementia. 

I  have  never,  in  my  own  experience,  known  death  to  take  place  dur- 
ing a  paroxysm  of  true  epilepsy  ;  such  cases,  however,  do  occur.  Usu- 
ally, some'  intercurrent  affection  carries  the  patient  off,  though  even 
with  this  liability  life  is  sometimes  astonishingly  prolonged.  I  am 
acquainted  with  the  case  of  a  lady  who  is  now  sixty-five  years  of  age, 
and  who,  since  her  tenth  year,  has  averaged  six  paroxysms  daily,  all  of 
the  severest  character.  Her  mind  is  almost  entirely  gone,  but  physi- 
cally her  health  is  excellent,  and  to  all  appearance  she  may  live  twenty 
years  longer. 

I  am  not  aware  of  any  exact  observations  tending  to  show  the  rela- 
tive danger  to  life  of  attacks  of  the  milder  and  severer  forms ;  though 
it  is  reasonable  to  suppose  that,  so  far  as  regards  the  occurrence  of 
death  during  the  paroxysm,  the  convulsive  form  is  more  fatal. 

Morbid  Anatomy. — In  post-mortem  examinations  of  persons  dying 
epileptic,  abnormal  conditions  are  found  in  every  part  of  the  brain  and 
spinal  cord.  Some  of  these  lesions  are  undoubtedly  secondary,  others 
unessential,  while  those  which  may  be  considered  primary  vary  in  then- 
seat  and  character.  In  a  great  many  cases,  perhaps  the  majority,  no 
lesions  are  discoverable. 

No  one  has  been  more  thorough  in  the  search  for  the  essential  cause 
of  epilepsy  than  Sehroeder  van  der  Kolk  ; '  though  his  observal  inns  ran 
scarcely  be  regarded  as  yielding  conclusive  results,  they  serve  to  shew, 

1  "  On  tli«:  Minute  Structure  aud  Functions  of  the  Medulla  Oblongata,  and  on  the  Proxi- 
mate Causes  and  Rational  Treatment  of  Epilepsy,"  "New  Sydenham  Socletj  Tiansla- 
lionfl,'1  London,  1859. 


682  CEREBRO-SPIXAL  DISEASES. 

when  taken  in  connection  with  the  pathology  of  the  disease  in  ques- 
tion, that  its  seat  is  mainly  in  the  medulla  oblongata,  with  second- 
ary implication  of  other  parts  of  the  cerebro-spinal  nervous  system. 
Oftentimes,  in  accordance  with  other  pathologists,  he  found  noth- 
ing to  account  for  the  affection,  but  at  others  he  found  hardening 
and  contraction  of  the  medulla  oblongata,  and  again  degeneration 
of  the  brain  either  as  a  consequence  or  cause  of  the  disease.  Mi- 
croscopical examination  sometimes  showed  him  the  medulla  indu- 
rated, sometimes  softened,  and,  as  a  constant  phenomenon,  "whether 
the  patient  died  in  or  out  of  the  fit,  great  redness  and  vascular  ten- 
sion in  the  fourth  ventricle,  penetrating  into  the  medulla  oblongata 
sometimes  to  a  considerable  depth."  These  appearances  were  due 
to  enlargement  of  the  blood-vessels,  as  -was  shown  by  microscopical 
measurements.  It  is  probable,  however,  as  Schroeder  van  der  Kolk 
asserts,  that  the  lesions  in  question  are  the  results,  and  not  the  causes, 
of  the  paroxysms. 

Other  observers  have  not  so  uniformly  found  this  enlargement  of 
the  blood-vessels  of  the  medulla.  In  three  cases  of  death  occurring  in 
epileptics,  in  which  I  have  had  the  opportunity  of  making  post-mortem 
examinations,  they  certainly  did  not  exist,  nor  was  there  any  other  le- 
sion detected  by  the  most  careful  microscopical  exploration.  In  one 
other  case  the  vessels  of  the  medulla  oblongata  were  enlarged,  and  there 
was  amyloid  degeneration  of  the  pituitary  body. 

Fox '  gives  the  following  list  of  the  post-mortem  appearances  : 
Foreign  bodies  developed  on  the  meninges,  in  the  ventricles,  in  the 
cortical  substance  ;  increase  of  subarachnoid  fluid  or  distention  of  the 
ventricles  by  serum,  induration,  softening,  and  general  swelling  of  the 
cerebral  mass  ;  general  or  partial  hyperemia,  cysts,  tubercles,  cancers, 
exostoses,  periosteal  growths,  thickening,  or  some  change  of  the  arach- 
noid or  the  pia  mater  ;  abnormal  thickness  or  abnormal  thinness  of  the 
cranial  bones  ;  excessive  size  of  head,  increase  of  the  volume  of  the 
cranial  cavity,  deformities  or  abnormality  in  the  conformation  of  this 
cavity  ;  caries  of  the  cranial  bones  ;  pus  between  the  bone  and  the  dura 
mater  ;  acute  or  chronic  hydrocephalus,  hydatids,  ossification  of  the 
dura  mater,  tubercle  of  the  dura  mater  or  pachymeningitis,  abscess  in 
the  cerebral  tissue,  spots  or  regions  of  hsemorrhage  ;  various  traumatic 
lesions  ;  alterations  of  the  pineal  gland  ;  inequality  of  weight  and  size 
of  the  cerebral  hemisphere  ;  various  lesions  connected  with  blood-ves- 
sels— aneurism,  embolism,  atheroma,  increase  in  size  of  the  capillaries 
in  the  medulla  oblongata,  fatty  degeneration  of  some  portion  of  the 
medulla  oblongata  ;  capillary  dilatation  in  the  pons  and  cerebellum  ; 
haemorrhage  of  pons;  anaemia  of  brain,  either  from  disease  of  vessels  or 
dependent  upon  general  anaemia,  etc.,  etc. 

1  "  The  Pathological  Anatomy  of  the  Nervous  Centres."  London,  1874,  p.  805. 


EPILEPSY.  683 

Indeed,  no  point  is  more  thoroughly  established  than  that  epilepsy- 
results  from  very  different  morbid  conditions,  and  that  they  are  simply 
the  starting-points  in  the  majority  of  cases.  The  true  lesion  has  not 
yet  been  detected,  and  in  fact,  as  we  shall  presently  see  when  discuss- 
ing the  pathology  of  the  disease,  there  may  be  no  necessary  anatomical 
lesion  whatever. 

Pathology. — The  points  which  may  be  considered  as  to  some  extent 
established  relative  to  the  pathology  of  epilepsy  are  briefly  summarized 
as  follows  by  Reynolds  : ' 

"  1.  That  the  seat  of  primary  derangement  is  the  medulla  oblongata 
and  upper  portion  of  the  spinal  cord. 

"  2.  That  the  derangement  consists  in  an  increased  and  perverted 
readiness  of  action  in  these  organs,  the  result  of  such  action  being  the 
induction  of  spasm  in  the  contractile  fibres  of  the  vessels  supplying  the 
brain,  and  in  those  of  the  muscles  of  the  face,  pharynx,  larynx,  respira- 
tory apparatus,  and  limbs  generally. 

"  By  contraction  of  the  vessels  the  brain  is  deprived  of  blood,  and 
consciousness  is  arrested;  the  face  is  or  may  be  deprived  of  blood,  and 
there  is  pallor  ;  by  contraction  of  the  vessels  which  have  been  men- 
tioned, there  is  arrest  of  respiration,  the  chest-walls  are  fixed,  and  the 
other  phenomena  of  the  first  stage  of  the  attack  are  brought  about. 

"  3.  That  the  arrest  of  breathing  leads  to  the  special  convulsions  of 
asphyxia,  and  that  the  amount  of  these  is  in  direct  proportion  to  the* 
perfection  and  continuance  of  the  asphyxia. 

"  4.  That  the  subsequent  phenomena  are  those  of  poisoned  blood, 
i.  e.,  of  blood  poisoned  by  the  retention  of  carbonic  acid,  and  altered 
by  the  absence  of  a  due  amount  of  oxygen. 

"  5.  That  the  primary  nutrition-change,  which  is  the  starting-point 
of  epilepsy,  may  exist  alone,  and  epilepsy  be  an  idiopathic  disease,  i.  e., 
a  morbus  per  se. 

"  6.  That  this  change  may  be  transmitted  hereditarily. 

"  7.  That  it  may  be  induced  by  conditions  acting  upon  the  nervous 
centres  directly,  such  as  mechanical  injuries,  overwork,  insolation,  emo- 
tional disturbances,  excessive  venery,  etc. 

"  8.  That  the  nutrition-changes  of  epilepsy  may  be  a  part  of  some 
general  metamorphosis,  such  as  that  present  in  the  several  cachexia^ — 
rheumatism,  gout,  syphilis,  scrofula,  and  the  like. 

"  9.  That  it  may  be  induced  by  some  unknown  circumstances  deter- 
mining a  relative  excess  of  change  in  the  medulla  during  t  he  general 
excess  and  perversion  of  organic  change  occurring  at  the  periods  of 
puberty,  of  pregnancy,  and  of  dentition. 

1  Op.  cit.,  p.  275,  and  more  fully  stated  in  his  "  Treatise  on  Epilepsy,  its  Symptoms, 
Treatment,  and  Relations  to  other  Chronic  Convulsive  Diseases,"  London,  1801,  chapter 
V.,  p.  238. 


634  CEREBRO-SPINAL   DISEASES. 

"10.  That  it  may  be  due  to  diseased  action,  extending  from  con- 
tiguous portions  of  the  nervous  centres  or  their  appendages. 

"  11.  That  the  so-called  epileptic  aura  is  a  condition  of  sensation  or 
of  motion,  dependent  upon  some  change  in  the  central  nervous  system, 
and  is,  like  the  paroxysm,  a  peripheral  expression  of  the  disease,  and 
not  its  cause." 

While  admitting  the  correctness  of  these  conclusions,  they  do  not,  in 
my  opinion,  tell  the  whole  story  of  the  theory  of  epilepsy.  In  very 
many  memoirs  Dr.  Brown-Sequard  has  pointed  out  the  dependence  of 
the  affection  upon  injuries  of  the  upper  part  of  the  spinal  cord,  and 
upon  irritations  existing  in  various  parts  of  the  body.  His  researches, 
and  facts  observed  every  day  by  physicians  who  see  many  cases  of  epi- 
lepsy, show  very  conclusively  that  the  starting-point  is  often  in  the 
sympathetic  nerve — the  nerve  by  which  the  calibre  of  the  blood-vessels 
is  regulated. 

Neither  can  I  accept  the  view  that  the  first  intra-cranial  condition 
producing  a  paroxysm  is  in  all  cases  spasm  of  the  blood-vessels  and  the 
consequent  deprivation  of  the  blood-supply  to  the  brain.  On  the  con- 
trarv,  I  am  very  sure  that  the  primary  state  is  often  paralysis  of  the 
cerebral  blood-vessels  and  resulting  hyperasmia.  By  this  condition  the 
medulla  oblongata  is  thrown  into  a  state  of  over-excitation,  giving  rise 
to  convulsions,  and  consciousness  is  lost  from  the  fact  that  the  hemi- 
spheres participate.  That  convulsions,  epileptiform  in  character,  may  be 
produced  both  by  cerebral  anaemia  and  cerebral  hypercemia,  when  either 
condition  involves  the  medulla  oblongata,  is  a  fact  which  experiment 
has  abundantly  established,  and  that  loss  of  consciousness  follows  either 
condition  involving  the  hemispheres  is  equally  certain.  We  have,  con- 
sequently, two  kinds  of  epilepsy — the  one  due  to  anaemia,  the  other  to 
congestion — and  it  is  to  this  fact  that  is  due  the  circumstance  that 
sometimes  the  paroxysms  are  prevented  by  measures  which  tend  to  in- 
crease the  amount  of  blood  in  the  brain,  and  at  others  by  remedies 
which  exercise  a  contrary  influence.  The  existence  of  the  two  species 
of  epilepsy  is  likewise  shown  by  ophthalmoscopic  examination — a  point 
upon  which  I  have  already  insisted. 

During  natural  sleep  the  amount  of  blood  is,  as  I  have  elsewhere 
shown,  decreased  from  the  quantity  which  circulates  in  the  cerebral 
blood-vessels  during  wakefulness.  Epilepsy  occurring  during  sleep  is 
therefore  of  the  anaemic  variety.  But  it  often  happens  that  sleep 
passes  gradually  into  stupor,  from  the  fact  that  causes  tending  to  in- 
crease the  flow  of  blood  to  the  brain,  or  to  arrest  its  passage  from  this 
organ,  are  in  operation.  In  such  cases  epilepsy  of  the  congestive  va- 
riety may  be  induced. 

In  those  cases  in  which  the  tongue  is  bitten,  the  medulla  oblongata 
is  probably  always  in  a  condition  of  hyperemia  ;  and  this  state,  as 
Schroeder  van  der  Kolk  has  very  conclusively  shown,  is  mainly  in  the 


EPILEPSY.  685 

course  of  the  roots  of  the  hypoglossal  nerve.  The  intermissions 
between  the  attacks  are  ingeniously  explained  by  the  same  able 
observer,  by  likening  the  cells  of  the  medulla  oblongata  to  Leydcn 
jars  charged  with  electricity,  or  to  the  electrical  organs  of  the  conger- 
eel  and  torpedo.  After  being  discharged,  time  is  necessary  for  the 
reaccumulation  of  sufficient  electricity  to  discharge  them  again  ;  and, 
when  the  cells  of  the  medulla  have  once  discharged  themselves  in 
an  epileptic  convulsion,  a  period  must  elapse  before  another  access 
can  take  place. 

Nothnagel1  believes  that  the  pons  Varolii  and  the  medulla  ob- 
longata are  the  seat  of  epilepsy,  and  that  it  is  in  these  centres  that 
we  are  to  look  for  the  anatomical  changes.  Although,  as  his  own 
experiments  as  well  as  those  of  Hitzig  show  that  epilepsy  may  be 
produced  by  irritation  of  the  cortical  substance  of  the  brain,  the  fact 
only  proves  that  such  irritation  is  an  exciting  cause,  and  is  no  more 
to  be  regarded  as  indicating  the  cortex  as  the  seat  of  the  disease 
than  the  fact  that  irritation  of  the  sciatic  nerve,  followed  by  epi- 
lepsy, indicates  that  part  of  the  nervous  system  as  containing  the 
essential  lesion. 

Operations  for  the  removal  of  cortical  tumors  for  the  cure  of  epi- 
lepsy, and  excision  of  portions  of  the  cortex  in  which  the  motor  cen- 
tres have  been  located,  have  rarely  been  followed  by  anything  more 
than  temporary  relief. 

The  foregoing  remarks  apply  in  the  main  to  that  form  of  epileptic 
seizure  characterized  by  convulsion.  In  the  imperfectly-developed  at- 
tacks the  implication  of  the  medulla  oblongata  must  be  very  slight,  the 
hemispheres  being  the  organs  mainly  affected,  and  the  condition  being 
sometimes  anaemic,  at  others  hyperaemic. 

It  must  not  be  supposed,  from  what  has  been  said,  that  simple  cere- 
bral anaemia  and  simple  cerebral  congestion,  attended  with  epileptiform 
convulsions,  are  identical  with  the  anaemia  and  congestion  of  epilepsy. 
This  disease  is  cerebral  anaemia  or  congestion  with  another  clement, 
the  exact  nature  of  which  we  do  not  understand,  but  which  is  certainly 
of  such  a  character  as  to  constitute  the  main  differentia]  point  between 
epilepsy  and  any  other  affection. 

A  chapter  on  epilepsy  would  be  manifestly  incomplete  without  a 
statement  of  the  views  held  by  Dr.  Ilughlings  Jackson5  relative  to  its 
pathology  and  natural  history.  According  to  this  eminent  authority 
those  parts  of  the  body  suffer  first  and  most,  from  convulsions  or  other 
manifestations  of  the  disease,  which  are  most  frequently  brought  into 
volitional  action,  and  those  parts   least  which  are  most  automatic  in 

1  M Epilepsia/'  in  '/:■  "Handhoch  der  Bpedellen   Pathologic  and  Therapie," 

iwiilftcr  Band,  "Krankbeiten  dee  Nervensystems,"  ii.,  swelter  Halfte,  pp,  250, 
'"On  tin.'  Anatomical,  Physiological  and   Pathological  Investigation  of  Epilepti 

uWcst  Killing  Lunatic  Asylum  Medical  Reports,"  vol.  iii.,  1878,  p.  :U5. 


686  CEREBRO-SPINAL   DISEASES. 

their  operation.  Thus  he  says,  in  a  paper  published  in  the  Lancet, 
February  1,  1873  : 

"  There  are  three  parts  where  fits  of  this  group  mostly  begin  : 
(1)  in  the  hand  ;  (2)  in  the  face,  or  tongue,  or  both  ;  (3)  in  the  foot. 
In  other  words,  they  usually  begin  in  those  parts  of  one  side  of  the  body 
which  have  the  most  voluntary  use.  The  order  of  frequency  in  which 
parts  suffer  illustrates  the  same  law.  I  mean  that  fits  beginning  in  the 
hand  are  commonest  ;  next  in  frequency  are  those  which  begin  in  the 
face  or  tongue,  and  rarest  are  those  which  begin  in  the  foot.  The  law 
is  seen  in  details.  When  the  fit  begins  in  the  hand,  the  index- finger 
and  thumb  are  usually  the  digits  first  seized  ;  when  in  the  face,  the 
side  of  the  cheek  is  first  in  spasm  ;  when  in  the  foot,  almost  invariably 
the  great-toe." 

As  Dr.  Jackson  says,  the  spasm  "  prefers,"  so  to  speak,  to  begin  in 
those  parts  which  have  the  most  voluntary  uses  ;  in  other  words,  in 
those  parts  which  have  the  more  leading,  independent,  separate  and 
varied  movements  ;  in  other  words  still,  in  those  parts  the  movements 
of  which  are  last  acquired — "  educated."  Physiologically,  a  voluntary 
part,  the  hand,  for  instance,  is  one  which  has  the  greater  number  of 
different  movements  at  the  greater  number  of  different  intervals  ;  that 
is,  the  more  "  varied  "  uses.  An  automatic  part,  the  chest,  for  exam- 
ple, is  one  which  has  the  greater  number  of  similar  movements  at  the 
greater  number  of  equal  intervals ;  shortly,  the  more  "  similar "  uses. 
Hence,  convulsions  which  begin  in  the  hand  usually  begin  in  the  thumb 
and  index-finger — in  the  most  voluntary  parts  of  the  body. 

An  epileptic  paroxysm  is  a  sudden,  excessive,  and  rapid  discharge 
of  gray  matter  of  some  part  of  the  brain.  Instead  of  working  off  its 
force  gradually  and  regularly,  it  explodes  it,  as  it  were.  The  gray  mat- 
ter which  is  the  seat  of  a  "  discharging  lesion  "  is  in  a  permanently  ab- 
normal state  of  nutrition,  and  hence  is  permanently  abnormal  in  func- 
tion. Thus  a  first  fit  is  a  discharge  of  a  part  which  has  for  some  time 
before  been  in  a  state  of  mal-nutrition.  And  a  still  further  inference  is 
that  such  "  causes  "  of  epilepsy  as  fright  are  only  determining  causes 
of  the  first  explosion. 

In  regard  to  this  latter  point,  I  am  entirely  in  accord  with  Dr.  Jack- 
son, We  frequently  see  cases  of  epilepsy  which,  we  are  told,  were  ori- 
ginally caused  by  a  mental  shock  of  some  kind.  But  if  the  shock  were 
in  reality  the  primary  cause  there  should  be  no  subsequent  epileptic 
seizures.  With  the  cessation  of  the  cause  the  effect  should  cease.  On 
the  contrary,  we  find  that  after  some  time,  generally  quite  long,  which 
of  itself  is  sufficient  to  show  that  the  continuance  is  not  due  to 
the  initial  convulsion,  a  second  occurs,  and  then,  after  a  shorter  in- 
terval, a  third,  and  so  on.  It  is  very  evident  that  if  the  fright  were 
the  cause  the  fits  would  be  more  frequent  at  first,  and  less  so  subse- 
quently. 


EPILEPSY.  687 

But  to  return  to  Dr.  Jackson's  views  : 

"  Epilepsy  is  not  a  particular  grouping  of  symptoms  occurring 
occasionally  ;  it  is  a  name  for  any  sort  of  nervous  symptom  or  group 
of  symptoms  occurring  occasionally  from  local  discharge,  whether 
the  discharge  puts  muscles  in  movement  or  not — that  is,  whether 
there  be  a  convulsion  or  not  matters  nothing  for  the  definition.  A 
paroxysm  of  subjective  sensation  of  smell  is  an  epilepsy  as  much  as  is 
a  paroxysm  of  convulsion  ;  each  is  the  result  of  sudden  local  dis- 
charge of  gray  matter. 

"  It  does  not  matter  for  the  definition  whether  there  be  loss  of  con- 
sciousness or  not ;  loss  of  consciousness  is  a  fundamental  thing  in  most 
of  the  accepted  definitions.  If  there  be  no  loss  of  consciousness  there 
is,  according  to  most  physicians,  not  epilepsy,  and  the  term  'epilepti- 
form '  is  used.  But,  even  when  using  the  term  epilepsy  in  the  ordinary 
sense  of  the  word,  the  separation  into  cases  where  there  is,  and  where 
there  is  not  loss  of  consciousness,  has  no  physiological  warrant.  It  is 
an  arbi  trary  distinction  of  psychological  parentage.  Loss  of  conscious- 
ness is  not  an  utterly  different  thing  from  other  symptoms.  It  is  not 
to  be  spoken  of  as  an  epiphenomenon  or  as  a  complication.  Conscious- 
ness has  of  course  anatomical  substrata  as  much  as  speaking  has.  The 
sensori-motor  processes  concerned  in  consciousness  are  only  in  degree 
different  from  others.  They  are  the  most  special  of  all  special  nervous 
processes,  the  series  evolved  out  of  all  other  (lower)  series. 

"  To  lose  consciousness  is  to  lose  the  use  of  the  most  special  of  aU 
nervous  firocesses  whatsoever.  If  those  parts  of  the  brain  be  first  af- 
fected by  strong  discharge  where  the  most  special  of  all  nervous  pro- 
cesses He,  there  will  be  loss  of  consciousness  at  the  outset.  If  processes 
of  subordinate  series  be  discharged,  loss  of  consciousness,  of  course, 
occurs  later.  For  example,  in  cases  of  convulsions  beginning  in  the 
hand,  consciousness  is  in  most  cases  lost  as  soon  as  or  just  before  the 
leg  is  reached  by  the  spasm.  In  these  cases  the  internal  process  will 
be  that  consciousness  is  lost  as  soon  as  the  most  special  of  all  processes 
are  reached  by  the  internal  discharge  (or  since  the  sensori-motor  pro- 
cesses underlying  consciousness  are  evolved  out  of  lower  series),  when 
as  large  a  quantity  of  a  subordinate  yet  important  series  is  put  /tors  de 
combat.  Uut,  of  course,  one  does  not  locate  consciousness  so  geograph- 
ically as  the  mere  words  we  must  use  seem  to  imply.  If  a  patient  sud- 
denly loses,  by  any  process,  the  use  of  any  large  part  of  either  of  the 
two  highest  divisions  <>f  the  nervous  system,  he  will  lose  consciousness. 

"  The  following  are  epilepsies  : 

"(1)  A  sudden  and  temporary  stench  in  the  nose,  with  transient 
■unconsciousness;  (:>)  a  Budden  and  temporary  development  of  blue 
vision  ;  (3)  spasm  of  the  right  side  of  the  face  with  stoppage  of 
speech;  (I)  tingling  of  the  index-finger  and  thumb,  followed  by 
spasm  of  the  hand  and  forearm  ;  (5)  a  convulsion  almost  immediately 


688  CEREBRO-SPINAL  DISEASES. 

universal,  with  immediate  loss  of  consciousness  ;  (0)  certain  vertigi- 
nous attacks. 

"All  these  six  seizures  are  alike,  in  that  each  results  from  an 
occasional  and  excessive  discharge  of  unstable  gray  matter.  This  is 
the  one  functional  alteration  of  nerve-tissue  underlying  the  different 
phenomena." 

Dr.  Jackson  then  goes  on  to  state  that  though  these  six  kinds  of 
seizures  are  alike  physiologically,  they  are  very  unlike  anatomically. 
That  is,  that  the  seat  of  the  discharging  lesion  is  different  for  each, 
and  he  urges  that  the  efforts  of  physicians  should  be  directed  to  the 
discovery  of  this  seat  from  a  consideration  of  the  character  and  locali- 
zation of  the  manifestation.  In  a  "  destroying  lesion,"  such,  for  in- 
stance, as  is  produced  by  cerebral  haemorrhage,  the  scientific  physician 
endeavors,  by  a  careful  study  of  the  phenomena,  to  determine  the  situa- 
tion of  the  injury,  but  in  cases  of  spasm  the  inquiries  rarely  relate  to 
anything  more  than  an  attempt  to  ascertain  the  character  of  the  con- 
vulsion.    That  this  is  true  is  not  to  be  doubted. 

Further,  Dr.  Jackson  asserts  that  by  comparing  the  phenomena 
produced  by  a  "  destroying  lesion  "  with  those  which  result  from  a 
"  discharging  lesion  "  we  may  obtain  very  important  data  for  further 
comparison. 

The  experiments  of  Ferrier,  Ilitzig  and  Fritsche,  and  others,  have 
proved  conclusively  that  destruction  of  certain  cortical  areas  is  invari- 
ably followed  by  paralysis  of  certain  muscles.  Irritation  of  the  same 
cortical  areas,  on  the  other  hand,  just  as  invariably  produces  spas- 
modic movements  in  the  same  muscles  which  were  previously  paralyzed 
by  a  destructive  lesion.  It  is  thus  definitely  proved  that  certain  mus- 
cles, or  groups  of  muscles,  are  in  intimate  relation  with  certain  groups 
of  cortical  cells.  The  precise  situation  of  these  various  groups  of  cells, 
or  "  centres,"  as  they  are  termed,  has  been  definitely  located  (see  p. 
337).  Thus  we  are  enabled,  in  cases  of  epilepsy  in  which  the  spasms 
are  unilateral,  or  confined  to  one  limb,  or  to  a  part  of  one  limb,  to 
locate  with  precision  that  part  of  the  cerebral  motor  cortex  which  is 
the  seat  of  irritation,  and  which  gives  rise  to  the  "  discharges  of  motor 
force."  Perhaps  it  would  be  too  much  to  say  that  Dr.  Jackson's  views 
should  be  adopted  in  their  entirety,  but  that  they  are  in  great  part  cor- 
rect every  physician  who  has  seen  much  of  the  very  important  disease 
to  which  they  relate  will  readily  admit.  The  point  in  regard  to  which 
I  should  be  most  disposed  to  differ  with  him  is  that  in  which  he  too 
sweepingly,  in  my  opinion,  classes  all  "occasional,  sudden,  excessive, 
rapid  and  local,  sensorial  or  motor  phenomena"  as  epileptic.  Thus,  I 
am  quite  sure  I  have  repeatedly  witnessed  "tingling  of  the  index-fin- 
ger and  thumb,  followed  by  spasm  of  the  hand  and  forearm,"  result 
from  injury  of  the  eccentric  nervous  system,  from  pressure  on,  or  other 
injury  of,  the  brachial  plexus,  for  instance.     Now,  although  such  lesion 


EPILEPSY.  689 

may,  under  certain  circumstances,  produce  such  intra-cranial  disorder 
as  eventually  to  cause  epilepsy,  knowing  what  we  do  of  the  functions 
of  the  nerves  and  the  effects  of  injuries  to  their  trunks,  we  need  not 
go  so  far  as  the  gray  matter  for  an  explanation  of  the  phenomena.  Ex- 
periments on  animals — and  indeed  as  I  have  repeatedly  witnessed  in  the 
human  subject — show  us  that,  even  when  a  nerve-trunk  is  divided,  irri- 
tation of  its  peripheral  extremity  will  give  rise  to  just  such  phenomena 
as  Dr.  Jackson  calls  epileptic,  except  in  the  one  point — not  an  essential 
one — of  "  tingling."  In  a  patient  whom  I  saw  in  the  Presbyterian 
Hospital  a  year  or  so  ago,  in  the  service  of  Dr.  Post,  the  median  nerve 
was  exposed  for  the  space  of  over  two  inches,  and  when  it  was  touched 
with  a  probe  or  the  finger,  tingling  in  the  skin  below  and  spasm  of  the 
muscles  of  the  forearm  were  at  once  produced. 

In  the  present  state  of  our  knowledge  it  appears  to  me  better  to 
regard  no  spasm  as  epileptic,  which  is  not  accompanied  with  loss,  or  at 
least  disturbance  of  consciousness.  The  experiments  of  Hitzig,  Fer- 
rier,  and  others,  certainly  throw  a  great  deal  of  light  on  the  nature  of 
the  epileptic  phenomena,  and  give  great  support  to  many  of  Dr.  Jack- 
son's arguments  ;  but  they  also  show  us  that  irritation  of  the  gray 
matter  of  the  brain  will  cause  spasms,  which,  though  partaking  to  a 
superficial  examination  of  the  character  of  epilepsy,  are  clearly  not  this 
disease,  even  as  Dr.  Jackson  regards  it.  It  is  true  that  such  irritation 
repeatedly  made  will  in  time  so  alter  the  properties  of  the  gray  matter 
as  to  lead  to  the  production  of  spontaneous  spasms,  which  may  be  epi- 
leptic, but  that  is  quite  a  different  thing. 

The  experiments  made  by  Dr.  Roberts  Bartholow  '  on  a  patient 
under  his  charge,  in  the  Good  Samaritan  Hospital  in  Cincinnati,  show 
that  both  disorders  of  sensibility  and  spasm  are  produced  in  the  human 
subject  by  irritation  of  the  gray  matter  of  the  cerebral  convolutions  ; 
but  in  this  case  the  phenomena  disappeared  as  soon  as  the  irritation 
ceased.  Such  transient  results,  clearly  and  distinctly  due  to  an  irrita- 
tion of  the  gray  matter,  may  be  epileptiform,  but  to  my  mind  they  are 
not  epileptic. 

But  quite  recently  Hitzig  a  has  succeeded  in  producing  true  epilepsy 
in  animals  by  irritating  the  cortical  centres  ;  after  a  shorter  or  longer 
period — a  day  to  five  or  six  weeks — spontaneous,  well-characterized 
epileptic  convulsions  ensued.  The  importance  of  such  observations  as 
those  of  Bartholow  and  Hitzig  can  scarcely  be  over-estimated. 

Brown-Seqward  lias  shown  that  epilepsy  may  be  oaused  by  irritation 
of  the  peripheral  nervous  system,  and  it  is  quite  certain  that  the  tin- 
gling and  spasm  of  the  hand,  which  are  at  first  perhaps  only  due  to  ec- 
centric lesions  or  derangements,  may  result  in  epilepsy. 

A  case  is  now  under  my  charge— a  young  gentleman  from  North 

1  American  Journal  of  the  Medical  8dence$}  April,  I  -'.  L. 
*  "Untersuchungru  oeber  daa  Gehirn,"  Berlin,  1874,  i>.  '271. 
45 


G90  CEREBROSPINAL   DISEASES. 

Carolina,  whom  I  saw  first  over  two  years  since.  At  that  time  it  was 
only  necessary  to  touch  the  left  side  of  his  neck,  over  the  middle  third 
of  the  sterno-mastoid  muscle,  to  induce  spasm  of  the  muscles  of  the 
neck,  shoulder,  and  face,  on  the  same  side,  unaccompanied  by  loss  of 
consciousness.  This  condition  had  apparently  been  induced  in  the  first 
instance  by  his  wearing  a  high  shirt-collar,  and  in  the  beginning  con- 
sisted of  nothing  more  than  a  slight  twitching  of  the  muscles  at  the 
left  angle  of  the  mouth.  Probably,  if  he  had  then  ceased  wearing  that 
kind  of  collar,  the  excessive  hyperesthesia  of  the  eccentric  nerves 
would  have  spontaneously  ceased.  As  it  was,  an  increase  of  all  the 
phenomena  took  place;  and  finally,  the  least  touch,  even  that  of  a 
camel's-hair  pencil  or  a  current  of  air,  was  sufficient  to  induce  a  spasm. 
Blistering,  cauterization,  and  all  kinds  of  local  anaesthetics,  were  tried 
in  vain,  but  eventually  they  ceased  under  the  use  of  large  doses  of  the 
bromide  of  sodium.  But  during  all  this  time,  unless  an  irritation  of 
some  kind — the  lighter  the  more  powerful,  for  strong  pressure  was  not 
an  efficient  agent — there  were  no  spasms.  That  such  a  condition  was 
evidence  of  a  strong  epileptoid  tendency  I  did  not  doubt,  and  n^  fore- 
bodings of  the  ultimate  result  were  fulfilled,  for  after  the  lapse  of  about 
two  years  he  returned  to  me  with  no  hyperassthsia  of  the  skin  of  his 
neck,  but  with  occasional  fully-developed  epileptic  paroxysms,  for  which 
he  is  now  under  treatment.  Inquiry,  however,  showed  that  they  were 
the  result  of  late  hours  and  indiscretions  in  diet,  and  that  apparently 
they  had  no  connection  with  the  former  series  of  attacks. 

Relative  to  this  subject  of  convulsion  without  loss  of  consciousness 
but  appearing  paroxysmally,  I  shall  have  some  remarks  to  make  in  the 
next  chapter,  under  the  head  of  "  Convulsive  Tremor." 

It  has  been  urged  by  some  writers  that  migraine  is  a  modified  epi- 
lepsy. Dr.  Hughlings  Jackson  would  certainly  regard  such  cases  as 
those  of  Sir  John  Herschel,  the  astronomer-royal,  the  late  Sir  C.  Wheat- 
stone,  Dr.  Hubert  Airy,  and,  going  farther  back,  those  of  Dr.  Parry 
and  Dr.  Wollaston,  as  genuine  epilepsy.  Dr.  Latham,1  in  his  very  in- 
structive little  book,  from  which  I  cite  these  examples,  quotes  as  fol- 
lows Sir  John  Herschel's  account  of  the  phenomena  observed  in  his 
own  case,  in  which  there  were  present  in  his  field  of  vision  irregular 
fortification-like  figures,  the  margins  of  which  were  colored  : 

"In  one  attack  in  myself,  which  occurred  while  I  was  conversing 
with  an  acquaintance,  I  soon  became  painfully  sensible  that  I  had  not 
the  usual  command  of  speech  ;  that  my  memory  failed  so  much  that  I 
did  not  know  what  I  had  said  or  had  attempted  to  say,  and  that  I  might 
be  talking  to  another." 

Dr.  Airy,  who  has  also  described  his  own  case,  says  : 

"Sometimes  the  speech  is  affected,  and  the  memory  at  the  same 

1  "  On  Nervous  or  Sick  Headache,"  Cambridge  (England),  18*73,  p.  10 ;  also,  Philo- 
sophical Magazine,  vol.  xxx.,  p.  21. 


EPILEPSY.  691 

time.  On  one  occasion  the  mouth  was  seen  to  be  drawn  to  one 
side."  .v 

In  a  young  female  who  came  under  Dr.  Latham's  observation,  and 
who  had  colored  spectra,  there  was  a  tingling  of  the  arm  and  the 
Bide  of  the  tongue,  and  on  the  same  side  with  the  spectra.  Her  sister 
and  father  were  affected  in  precisely  the  same  way.  In  another  case 
the  patient  complained  of  a  feeling  of  pinching  and  scratching  on  that 
side  of  the  face  corresponding  with  the  glimmering. 

In  most  of  these  cases  these  spectra  and  sensations  were  followed 
by  headache  of  severe  character,  attended  with  nausea  and  vomiting. 

But,  notwithstanding  the  resemblance  to  epilepsy  which  all  these 
phenomena  of  migraine  suggest,  Dr.  Latham  asserts  that  it  differs 
widely  from  that  terrible  disorder  in  that  it  never  threatens  life,  is 
never  associated  with  unconsciousness,  and  that  he  has  never  known 
it  to  pass  into  epilepsy.  On  the  contrary,  with  advancing  age  the  at- 
tacks, as  a  rule,  become  much  less  frequent.  They  cease  generally  after 
fifty  or  sixty,  and  in  women,  not  uncommonly,  at  the  change  of  life. 

Dr.  Latham  holds  the  view  that  migraine  is  an  affection  of  the  sym- 
pathetic system;  that  the  ocular  spectra  are  the  result  of  an  anaemic 
condition  of  the  brain  due  to  a  tonic  contraction  of  the  arteries;  and 
that  the  pain  which  subsequently  appears  is  the  result  of  arterial  relax- 
ation and  consequent  cerebral  congestion. 

In  his  most  thorough  and  valuable  work  Dr.  Liveing '  discusses  the 
whole  subject  of  migraine  in  all  its  relations;  and,  while  admitting  with 
Marshall  Hall,  Sieveking  and  others  that  very  intimate  relations  exist 
between  sick-headache  and  epilepsy,  and  adducing  several  examples  in 
which  epilepsy  has  occurred  to  persons  who  were  in  previous  years  sub- 
ject to  the  former  affection,  nevertheless  regards  such  occurrences  as 
quite  exceptional,  and  as  instances  only  of  that  occasional  metamor- 
phosis of  neuroses  so  often  witnessed. 

That  migraine  is  an  affection  of  the  vaso-motor  system  is  rendered 
very  probable  by  the  observations  of  Mollendorff,2  who  reaches  the  con- 
clusion that  it  is  the  consequence  of  arterial  hyperemia.  He  found 
that  ophthalmoscopic  examination  of  the  eye  of  the  affected  side  re- 
vealed the  existence  of  dilatation  of  the  arteria  centralis  retime  as  well 
as  of  the  choroidal  vessels  and  of  a  bright-scarlet  color  of  the  fundus, 
while  on  the  other  side  the  vessels  were  normal,  and  the  fundus,  of  its 
usual  dark-red  color. 

This  theory  is  adopted  by  Dr.  Bergen3  in  a  recent  elaborate  paper. 
It  i.s  the  very  opposite  to  that  proposed  by  Dr.  Bois-Reymond,  ac< 

1  "On  Megrim,  Sick-bi  tdache,  and  some  Allied  Disorders,  a  Contribution  to  the  Pa- 

London,  1878. 
''  "  deber  Bemicrania,"  Arehiv.f  >nie,  Band  xL,  p.  385. 

8  "  On  the  Pal  of  Bemiorania,"  translation  from    the  Qerman  by  Pr.  n. 

Gradlr(  in  the  Journal  of  Jferwmt  attd  Mmtai  Diteatea,  vol.  i.,  187-1,  p.  296. 


692  CEREBRO-SPINAL   DISEASES. 

ins:  to  which  migraine  is  due  to  a  tetanic  contraction  of  the  cerebral 
arteries.  Neither  of  these  authors  regards  migraine  as  a  form  of  epi- 
lepsy. 

My  experience  with  sick-headache  has  been  quite  extensive.  I  have 
frequently  witnessed  cases  in  which  there  were  chromatic  ocular  spectra 
such  as  those  described  by  Latham,  Sieveking,  and  others,  but  I  have 
never  perceived  anything  more  in  the  most  marked  forms  of  the  affec- 
tion than  a  resemblance  to  some  of  the  phenomena  of  the  epileptic 
attack.  One  very  noticeable  difference  is  as  regards  the  effect  upon 
the  mind.  In  epilepsy  the  slightest  and  most  transient  seizures  gener- 
ally impair,  after  a  time,  the  mental  faculties,  especially  the  memoiy, 
while  in  migraine,  no  matter  how  severe  or  how  frequent  may  be  the 
attacks,  the  mind  in  all  its  parts  retains  its  full  vigor. 

There  seems  to  be  little  or  no  doubt,  therefore,  that  epilepsy  is 
the  result  of  cerebral  irritation,  which  finally  culminates  in  a  sudden 
discharge  of  nerve-force.  The  seat  of  the  discharge  may  be  either  in 
the  cortex  or  in  the  medulla  oblongata.  There  is  some  evidence,  how- 
ever, which  tends  to  show  that  even  where  the  primary  irritation  is 
cortical  the  spasms  are  the  result  of  the  reflection  of  this  irritation  to 
the  "epileptic  centre"  in  the  medulla. 

Treatment. — The  treatment  of  epilepsy  rests  almost  solely  on  ex- 
perience. To  attempt  the  consideration  of  all  the  means  which  have 
been  employed  would  be  a  fruitless  task,  even  though  it  were  possible. 
I  shall  therefore  content  myself  with  detailing  the  measures  which  I 
have  found  most  useful. 

Among  medical  remedies  the  bromides  stand  preeminent,  and  should 
be  thoroughly  tried  first  in  every  case.  The  bromide  of  potassium, 
sodium,  or  calcium  may  be  used.  Of  these,  the  bromide  of  sodium  is 
the  most  advantageous  in  the  majority  of  cases.  Its  taste — that  of 
common  salt — is  not  unpleasant,  and  it  agrees  better  with  the  digestive 
system  than  the  potassium  compound.  The  bromide  of  calcium  de- 
ranges the  system  still  less,  but  its  taste  is  not  so  pleasant,  and  it  is 
much  more  expensive.  Whichever  one  is  preferred,  the  dose  for  an 
adult  in  ordinary  cases  and  in  the  beginning  of  the  treatment  is  fifteen 
grains  three  times  a  day  in  solution. 

It  must  be  clearly  understood  that  the  bromide,  if  successful  in 
arresting  the  convulsions,  must  be  taken  for  a  long  time,  in  order  to 
increase  the  probability  of  a  cure.  I  never  discontinue  it  under  two 
years,  and  sometimes  persevere  with  it  still  longer,  if  in  the  mean  time 
there  have  been  attacks  of  vertigo,  auras,  or  other  epileptoid  manifesta- 
tions. 

After  the  initial  doses  have  been  given  for  about  two  months,  if 
there  are  no  symptoms  indicating  extreme  bromism,  or  if  there  has  been 
no  paroxysm,  I  increase  the  doses  by  one-half.  If  there  have  been 
paroxysms  in  the  mean  time,  I  increase  one-half  after  each  paroxysm, 


EPILEPSY.  693 

until  they  are  arrested,  or  until  I  am  satisfied  that  the  bromide  is  ineffi- 
cacious or  injurious.  I  have  sometimes  been  compelled  to  carry  it  to 
the  extent  of  nearly  two  hundred  grains  a  day,  and  to  continue  it  at 
that  quantity  for  eight  or  ten  days.  "When  the  system  is  thoroughly 
under  the  influence  of  the  remedy  and  the  convulsions  have  ceased,  the 
doses  may  be  reduced;  but  they  should  not  be  discontinued. 

The  bromides  are  less  efficacious  in  the  nocturnal  variety  of  epilep- 
tic seizures,  and  in  those  which  consist  mainly  of  loss  of  consciousness, 
than  in  the  diurnal  and  strongly  convulsive  kinds.  In  the  former, 
sometimes,  they  increase  the  number  and  severity  of  the  attacks,  and 
in  such  cases  should  of  course  be  at  once  discontinued. 

A  point  connected  with  their  action  must  not  be  overlooked,  and 
that  is,  the  cachexia  which  so  generally  attends  their  administration  in 
large  doses.  In  a.  memoir,1  published  over  six  years  ago,  and  which  has 
been  cited  in  another  connection,  I  brought  forward  several  cases  in 
which  this  cachexia  had  been  produced.  Greatly-increased  experience 
has  convinced  me  that,  though  in  general  it  never  causes  any  perma- 
nently ill  effects,  frequently  great  constitutional  disturbance  is  in- 
duced. In  three  cases  large  carbuncles  were  caused,  in  a  few  I  have 
been  obliged  to  suspend  for  a  time  the  administration  of  the  medicine, 
and  in  two  cases  death  resulted,  in  one  from  the  patient  taking  larger 
doses  than  were  prescribed,  and  continuing  them  while  not  under  my 
immediate  care,  and  in  the  other  from  the  supervention  of  pneumonia 
while  under  the  full  influence  of  the  remedy. 

But,  I  am  very  sure  that  the  bromic  cachexia  is  favorable  to  the  eradi- 
cation of  the  epileptic  tendency,  and  I  therefore  endeavor  to  produce  it 
as  soon  as  possible.  It  appears  in  many  cases  to  alter  the  whole  organ- 
ism of  the  patient  to  such  an  extent  as  to  leave  him,  when  it  disap- 
pears, with  his  nutritive  processes  and  his  proclivities  so  modified  that 
epilepsy  is  no  longer  possible.  The  physician  will  require  all  his  firm- 
ness and  courage  to  persevere  in  those  cases  in  which  the  bromism  is 
extreme,  but  he  should  not  yield  unless  the  phenomena  are  so  intense 
and  the  strength  of  the  patient  so  greatly  reduced  as  to  excite  his 
gravest  apprehensions. 

The  phenomena  indicative  of  bromism  will  be  given  further  on  under 
the  head  of  toxic  affeol  iona  of  the  nervous  system.  It  may  be,  however, 
mentioned  here  thai  in  the  peculiar  faculty  possessed  by  the  bromides 
of  lessening  the  reflex  excitability  of  the  pharynx  we  have  a  ready 
means  of  ascertaining  the  extent  to  which  the  system  is  under  the  ac- 
tion of  i he  remedy.    If  the  handle  <>f  a  spoon  be  pressed  gently  against 

the  posterior  wall  of  the  pharynx  of  a  healthy  person,  slight  nausea  and 

efforts  to  vomit  are  a1  once  excited  ;  but,  if  Buch  a  prison  be  subse- 
quently brought  fully  iiinler  the  influence  of  any  one  of  the  bromides, 

1  "<>n  some  of  the  Effects  <>f  the  Bromide  of  Potassium  trhen  administered  iu  Largo 
Dose*,"  Journal  of  Ptychological  MeoHeine^  January,  1869,  p.  46. 


G94  CEREBRO-SPINAL  DISEASES. 

the  irritability  of  that  part  is  destroyed,  so  that  nausea  or  vomiting  is 
no  longer  excited  by  pressure. 

Herpin  !  several  years  ago  called  attention  to  the  salts  of  zinc  in  the 
treatment  of  epilepsy.  He  preferred  the  oxide,  and  for  a  long  time  I 
made  extensive  use  of  this  preparation  in  the  treatment  of  the  disease 
in  question.  Latterly,  however,  I  have  used  the  lactate,  and  still  more 
recently  the  bromide,  with  very  definitely  beneficial  results.  It  is  best 
administered  in  the  form  of  a  sirup — my  formula  is  :  I>.  Zinci  bromidi, 
3  j  ;  syrupus  simplicis,  3  j.  M.  ft.  sol. — which  may  be  given  in  doses  of 
ten  drops  gradually  increased  to  thirty  or  more  three  times  a  day.  It 
should  be  given  largely  diluted,  as  being  the  less  apt  to  excite  nausea. 

In  several  cases  the  bromide  of  zinc  has  proved  exceedingly  effica- 
cious thus  far  in  arresting  the  paroxysms  where  other  bromides  had 
failed.  Bromism  is  not  an  attendant  on  its  administration,  and  yet  it 
is  quite  probable  that  the  bromine  of  the  compound  exercises  consid- 
erable curative  influence.  I  have  given  it  as  long  a  time  as  six  months 
consecutively  without  producing  cachexia,  and  to  the  extent  in  some 
cases  of  forty  grains  a  day. 

A  troublesome  feature  which  often  attends  the  administration  of  the 
bromides — except  the  zinc  compound — is  the  cutaneous  eruption. 
Arsenic  has  been  said  to  obviate  the  tendency  to  this  complication,  and 
to  cure  it  where  already  present.  In  a  few  cases  I  have  seen  the  use  of 
the  drug — four  or  five  drops  of  Fowler's  solution  with  each  dose  of  the 
bromide — prove  serviceable  ;  but  in  the  majority  of  cases  it  has  ap- 
peared to  be  inefficacious.  Owing  to  the  supervention  of  carbuncles 
with  a  strong  predisposition  to  gangrene  of  the  skin,,  I  have  been 
obliged  in  several  cases  to  discontinue  the  bromide  of  potassium.  The 
calcium  compound  is,  I  think,  not  so  liable  as  those  of  potassium, 
sodium,  or  ammonium,  to  cause  this  trouble. 

In  the  nocturnal  form  of  epilepsy  strychnia  is  sometimes  remarkably 
efficacious.  It  may  be  given  in  the  beginning  in  the  dose  of  the  thir- 
tieth of  a  grain  three  times  a  day  gradually  increased.  A  good  for- 
mula for  its  administration  is  :  I£  Strychnia  sulph.,  gr.  ij  ;  aqua  dest., 
Z  j.  M.  ft.  sol.  Dose,  eight  drops  three  times  a  day  for  the  first  two 
weeks,  then  nine  drops  for  the  next  two  weeks,  increasing  a  drop  every 
two  weeks  for  a  year,  and  perhaps  longer. 

Strychnia  is  also  said  to  be  useful  in  epilepsy  of  stomachal  origin — 
that  is,  cases  produced  by  gastric  derangement. 

The  nitrite  of  amyl,  first  proposed  and  used  in  epilepsy  by  Dr.  Weir 
Mitchell,  is  certainly  beneficial  in  arresting  the  paroxysm,  when  there 
is  an  aura  sufficiently  pronounced  and  slow  to  give  the  patient  the  time 
to  employ  it.  Five  to  ten  drops  may  be  inhaled  from  a  handkerchief 
with  safety,  and  generally  with  success.  As  there  is  generally  not  time 
to  pour  it  out,  this  quantity  should  always  be  kept  on  the  person  in  a 
1  "Du  pronostic  et  du  trakeinent  curatif  dc  l'6pilcpsie,"  Paris,  1852. 


EPILEPSY.  695 

glass-stoppered  vial  ready  for  use  at  a  moment's  notice.  Dr.  McBride, 
of  this  city,  has  had  made  little  hollow  thin  glass  beads  containing  the 
proper  quantity  of  the  nitrite  of  amyl,  and  when  the  patient  experi- 
ences the  warning,  one  of  these  is  crushed  in  a  handkerchief  and  the 
vapor  inhaled  through  the  mouth. 

Dr.  Crichton  Browne  '  has  not  only  used  the  nitrite  of  amyl  in  pre- 
senting individual  paroxysms,  but  has  given  it  with  advantage  with 
the  view  of  breaking  up  the  status  epilepticus — a  condition  in  which  the 
fits  succeed  each  other  with  scarcely  an  intermission,  the  patient  being 
unconscious  during  such  intervals  as  occur.  The  results  of  his  expe- 
rience are  such  as  to  convince  him  that  it  will  be  found  invaluable  in 
many  cases,  not  only  in  postponing  the  paroxysm,  but  altogether  pre- 
venting epileptic  seizures. 

It  may  be  stated  that  the  effect  of  the  nitrite  when  inhaled  is  to  ac- 
celerate  the  action  of  the  heart,  to  make  the  face  red,  and  to  cause  a 
feeling  of  fullness  in  the  head,  and  a  sensation  as  if  pins  and  needles 
were  sticking  into  the  skin  of  the  face,  neck,  and  chest.  These  phe- 
nomena disappear  in  a  few  moments. 

Within  the  last  few  years  I  have  used  the  nitrite  of  amyl  internally 
with,  in  some  cases,  decided  benefit.  It  may  be  given  in  doses  of  from 
half  a  drop  up  to  three  or  four,  gradually  increased,  if  necessary,  and 
should  be  continued  for  a  longtime.  A  good  formula  is  :  I£.  Amyl 
nit.,  TTg  x  ;  alcoholis,  ffg  xc.  M.  ft.  sol.  Dose,  from  five  to  twenty 
or  thirty  drops  a  day.  I  usually  begin  with  five  drops  on  a  lump  of 
sugar,  morning,  afternoon,  and  bedtime,  increasing  the  doses  one  drop 
every  week  so  long  as  it  continues  to  control  the  disease. 

Several  cases  of  epileptiform  seizures  clearly  due  to  syphilitic  infec- 
tion  have  been  under  my  charge,  and  have  been  treated  with  benefit  by 
the  bromides  in  conjunction  with  the  iodide  of  potassium.  In  five  of 
these,  cures  are  known  to  have  been  effected. 

As  regards  other  medicinal  remedies  for  epilepsy,  I  have  but  little 

ay.  B<  lladonna  has  never  in  my  hands  produced  the  least  good 
effect,  neither  lias  the  nitrate  of  silver,  nor  indigo,  nor  cotyledon  um- 
bilicus, DOT  digitalis,  nor  any  of  the  salts  of  copper.  The  same  may  be 
said  of  a  hundred  other  substances  less  favorably  known.  Hydrate  of 
chloral  in  three  cases  mitigated  the  frequency  of  the  paroxysms,  bat 
only  for  a  short  time  Calabar  Wean  was  slightly  beneficial  in  one  cast'. 
Borax,  after  a  \<ry  full  trial,  absolutely  failed. 

lint  the  whole  treatment  of  epilepsy  is  not  confined  to  drugs.  Sur- 
gical and  hygienic  measures  are  often  in  the  highest  degree  beneficial, 
and  the  latter  should  he  brought  into  action  in  every 

Of  the  BUrgioal  means  the  excision  of  any  cicatrix  which,  by  entan- 
gling a  nerve,  may  l.e  a  Bource  of  reflex  irritation,  is  occasionally  a 

1  "Nitrite of  Amyl  in  Epilepsy,"  "West  Riding  Lunatic  Asylum  Medical  Reports,' 
vol.  iii.,  1873,  p.  151. 


696  CEREBRO-SPINAL   DISEASES. 

useful  measure.  This  poiut  has  been  brought  forward  in  an  inter- 
esting memoir  by  Dr.  F.  D.  Lente,1  in  connection  with  cicatrices  of 
the  scalp,  but  the  like  reasoning  and  action  are  applicable  to  cica- 
trices existing  in  any  other  part  of  the  body  from  which  an  aura 
appears  to  start. 

In  injuries  of  the  skull,  followed  by  epilepsy,  trephining  may  be  of 
great  service.  It  has  been  aptly  said  that  no  blow  upon  the  head  is 
slight  enough  to  be  despised,  and,  so  far  as  epilepsy  is  concerned,  this 
is  preeminently  true.  I  have,  during  the  past  five  years,  trephined 
twenty-three  times  for  epilepsy  which  was  apparently  due  to  cranial 
injuries.  In  seven  of  these  the  fits  ceased,  and  in  two  of  the  seven 
cases  there  was  neither  fracture  nor  depression.  Of  the  remaining 
sixteen  cases  there  was  no  cranial  injury  to  be  found  in  three  ;  and  in 
thirteen,  though  there  was  such  injury,  the  operation  proved  unsuc- 
cessful, though  beneficial  results  in  lessening  the  frequency  of  the 
attacks  were  obtained  in  the  majority.  In  one  of  them  the  fits  did  not 
recur  for  over  a  year.  The  fact  that  in  two  of  the  successful  cases 
no  fracture  or  depression  was  found  is  a  strong  point  in  favor  of  Dr. 
Lente's  view  that  epilepsy  is  sometimes  the  result  of  a  cicatrix  of  the 
scalp,  for,  in  both,  the  incisions  in  the  scalp,  as  in  all  the  others,  were 
made  so  as  to  include  the  scalp-wound. 

In  those  cases  in  which  the  spasms  are  confined  to  one  side  of  the 
body,  to  one  leg,  to  one  arm,  or  to  one  side  of  the  face,  trephining 
over  the  motor  centre  involved,  and  the  removal  of  the  tumor  or  the 
excision  of  the  diseased  area  of  cortex,  should  be  insisted  upon  as  soon 
as  the  precise  character  of  the  disease  can  be  ascertained. 

As  the  result  of  my  experience,  I  am  decidedly  of  the  opinion  that, 
in  all  cases  of  epilepsy  in  which  there  is  injury  of  the  skull  or  scalp, 
trephining  or  excision  of  the  cicatrix  should  be  performed,  as  may  be 
proper. 

In  some  cases  counter-irritation  to  the  nape  of  the  neck  is  decidedly 
beneficial.  It  may  consist  either  of  a  seton,  which  may  be  left  in  for 
several  months,  or  the  repeated  application  of  the  actual  cautery. 
Counter-irritation  is  especially  indicated  in  those  cases  in  which  the 
tongue  is  bitten,  and  instances  in  which  internal  remedies  have  failed 
till  they  were  supplemented  by  this  means  are  not  uncommon. 

The  hygienic  management  of  the  patient  is  important.  A  large  por- 
tion of  the  clay  should  be  passed  in  the  open  air  ;  bodily  exercise  should 
be  regular,  but  not  excessive  ;  the  food  should  be  nutritious,  but  neither 
exciting  nor  indigestible.  The  importance  of  avoiding  every  aliment- 
ary substance  calculated  to  cause  gastric  or  intestinal  irritation  cannot 
be  over-estimated.     I  have  frequently  seen  paroxysms  directly  caused 

1  "Neuralgia  and  other  Neuroses  arising  from  Cicatrices  of  the  Scalp,  and  their 
Surgical  Treatment,"  "  Transactions  of  the  American  Neurological  Association,"  vol.  i., 
New  York,  1875,  p.  157. 


EPILEPSY.  697 

by  nuts,  dried  fruits,  pastry,  heavy  and  badly-baked  bread,  excess  in 
the  use  of  alcoholic  liquors,  confectionery,  and  the  like.  And  a  diet 
consisting  mainly  of  farinaceous  substances  is  certainly  preferable  to 
one  in  which  meat  forms  the  larger  part.  I  have  in  three  cases  effected 
entire  cures  by  confining  the  patients  for  several  months  to  a  diet  con- 
sisting at  first  of  skim-milk,  to  which  after  a  time  a  little  bread  was 
added.  The  bowels  must  be  kept  regular.  Baths  should  be  frequently 
taken,  but  should  not  be  so  cold  as  to  cause  severe  shock  or  physical 
depression.  Turkish  baths,  I  am  inclined  to  think,  are  useful  in  many 
cases,  particularly  in  those  occurring  in  persons  of  full  and  gross  habit 
of  body. 

Overheated  and  ill-ventilated  apartments  should  be  avoided.  The 
clothing  should  be  warm  in  winter  and  cool  in  summer.  The  mind 
should  not  be  overtasked,  and  the  emotions  must  not  be  unduly  excited. 

Individual  attacks  may  sometimes  be  prevented  by  other  means 
than  the  nitrite  of  amyl.  One  gentleman  under  my  charge  assures  me 
that  he  can  often  dissipate  the  premonitary  symptoms,  and  thus  stop 
the  development  of  the  paroxysm,  by  a  strong  exertion  of  the  will. 
Another  can  arrest  them  sometimes  by  changing  the  position  of  his 
bcdy.  If  standing,  he  lies  down  ;  if  lying  down,  he  rises  sudden^  and 
paces  the  room  violently.  Another  stops  them  by  putting  salt  in  his 
mouth,  and  two  can  frequently  prevent  them  by  tightening  straps  which 
I  have  instructed  them  to  keep  constantly  around  the  wrist.  In  all 
these  cases  there  is  an  aura,  and  in  the  two  latter  it  appears  to  start 
from  the  hand. 

But,  before  resorting  to  any  specific  treatment  for  epilepsy,  diligent 
search  should  be  made  for  the  cause,  and  this  should  be  removed,  if 
possible,  without  the  least  delay.  Often  an  eccentric  irritation,  such 
as  worms  in  the  intestinal  canal,  implication  of  a  nerve  in  an  injury, 
disorders  of  menstruation,  etc.,  can  be  discovered,  without  the  removal 
of  which  a  permanent  cure  is  impossible.  In  several  of  the  cases  cited, 
success  in  the  treatment  was  in  a  great  measure  due  to  acting  on  this 
principle. 

Tin'  treatment  during  the  paroxysm  remains  to  be  considered.  It 
is  simple,  and,  beyond  a  few  obvious  measures,  consists  in  letting  tho 
patient  alone.  The  head  should  be  elevated,  the  collar  and  cravat 
loosened,  a  piece  of  soft  wood  put  between  the  teeth  so  as  to  prevent 
injury  to  the  tongue,  and  the  patient  so  placed  thai  he  cannol  fall  or 
otherwise  injure  himself  in  his  struggles.  During  the  subsequent 
stupor  In'  Bhould  be  kept  quiet.  Bloodletting  is  never  necessary, 
although  it  is  recommended  as  proper  in  certain  oases  by  Jaccoud. 


698  CEREBRO-SPINAL   DISEASES. 

CHAPTER  III. 

CONVULSIVE    TREMOR. 

Under  the  designation  of  convulsive  tremor,  I  propose  to  include 
all  those  cases  of  non-rhythmical  tremor  or  clonic  convulsive  move- 
ments which  are  unattended  with  loss  of  consciousness,  but  "which, 
nevertheless,  are  paroxysmal  in  character. 

As  the  affection  has  not  yet  found  its  way  into  the  systematic  trea- 
tises, I  shall,  as  in  the  matter  of  spinal  irritation,  devote  a  few  words 
to  its  history,  and,  in  so  doing,  shall  draw  largely  from  a  paper  of  ray 
own  on  the  subject,  published  over  eight  years  ago,1  and  from  a  clinical 
lecture2  delivered  to  the  class  at  the  Bellevue  Hospital  Medical  College 
in  the  winter  of  1871-'72. 

A  few  years  ago  Friedreich 3  reported  a  case  of  what  he  termed 
paramyoclonus  multiplex,  which  differs  in  no  essential  particular  from 
the  cases  described  in  this  chapter.  There  is  a  tendency  on  the  part 
of  some  observers  to  regard  paramyoclonus  multiplex  and  convulsive 
tremor  as  two  distinct  affections,  without  there  being,  in  my  opinion, 
any  just  grounds  for  so  doing. 

History  and  Symptoms. — In  the  year  1822  Dr.  Pritchard,4  under  the 
name  of  convulsive  tremor,  gave  an  account  of  two  cases,  presenting 
somewhat  similar  features  to  the  one  before  us.  His  attention  was 
first  directed  to  the  subject  by  noticing  that,  in  some  epileptic  patients 
who  had  come  under  his  observation,  fits  of  tremor  occurred  in  the  in- 
tervals between  the  paroxysms  and  even  appeared  to  take  the  place  of 
the  ordinary  seizure.  He  then  noticed  several  cases  in  which  there 
wrere  no  epileptic  attacks,  but  in  which  there  were  violent  clonic  spasms 
of  the  muscles,  accompanied  with  severe  pain  in  the  head  and  profuse 
perspiration.  Dr.  Pritchard  states  that,  previous  to  his  observations, 
the  affection  had  not  attracted  much  attention  ;  but  he  cites  a  case 
from  Tulpius  of  a  young  unmarried  woman,  of  a  pale  complexion  and 
phlegmatic  temperament,  who  was  afflicted  during  three  years  with 
what  was  called  the  shaking-palsy,  which  did  not  affect  her  constantly, 
but  came  on  in  periodical  fits;  each  paroxysm  lasted  nearly  two  hours, 
and  was  accompanied  by  hoarseness  and  loss  of  voice,  the  consciousness 
being  unimpaired. 

He  also  refers  to  other  cases  quoted  by  Sauvages  from  Bonetus,  in 
which  the  symptoms  Avere  very  similar,  consisting  of  convulsive  tremor, 
attended  with  headache  and  vertigo.  This  disorder  was  fatal  in  a  few 
days,  and  after  death  a  parasite  was  found  in  the  brain.     In  this  con- 

1  "On  Convulsive  Tremor,"  New  York  Medical  Journal,  June,  18C7,  p.  185. 

2  "Clinical  Lectures  on  Diseases  of  the  Nervous  System,"  New  York,  1874,  p.  164. 
8  Virchovj's  Archives,  Bd.  lxxxvi.,  p.  421. 

4  "A  Treatise  on  Diseases  of  the  Nervous  System,"  London,  1822,  p.  393. 


CONVULSIVE  TREMOR.  699 

nection  it  is  interesting  to  recall  the  fact  that  the  sheep  is  subject  to  a 
somewhat  similar  train  of  symptoms,  due  to  the  presence  of  an  ento- 
zoOn  in  the  brain. 

Dr.  Pritchard  then  relates  his  own  cases,  of  which  the  following  ac- 
count is  an  abstract: 

John  Pugh,  a  carpenter,  of  meagre  habit,  low  stature,  and  dark 
hair,  aged  fifty,  was  admitted  into  St.  Peter's  Hospital  March  1,  1820. 
About  a  month  previously  he  had  suffered  from  tonsillitis  and  subse- 
quently had  some  difficulty  of  breathing,  which  was  supposed  to  be 
asthmatic.  He  had  complained  of  headache  for  some  time.  On  the 
23d  of  February  he  was  attacked  with  a  violent  tremor,  which  con- 
tinued for  two  or  three  hours,  and  then  went  off  after  he  had  taken  an 
emetic.  It  recurred  on  the  following  day  at  the  same  time,  and  on 
every  succeeding  day  about  the  same  hour.  At  the  time  of  his  admis- 
sion he  was  laboring  under  a  paroxysm. 

On  first  looking  at  the  man,  Dr.  Pritchard  supposed  him  to  be  in 
the  cold  stage  of  intermittent  fever,  but  on  closer  and  more  careful  ex- 
amination his  affection  was  seen  to  be  very  different.  All  the  muscles 
of  the  upper  extremities,  including  those  connected  with  the  ribs,  clav- 
icle, and  scapula,  were  constantly  agitated  by  a  convulsive  movement 
which  was  almost  entirely  confined  to  them.  The  lower  extremities 
were  quite  free  from  disorder.  The  man  was  perfectly  conscious,  and 
able  to  answer  any  question  distinctly.  His  pulse  was  quick  and  ap- 
parently irregular.  Owing  to  the  constant  agitation  of  the  tendons  it 
was  impossible  to  arrive  at  certainty  on  this  latter  point.  The  skin 
was  warm,  and  there  was  no  sensation  of  chilliness.  The  upper  part  of 
the  body  was  in  a  state  of  profuse  perspiration.  He  complained  of  ver- 
tigo and  headache. 

Bloodletting  was  ordered;  a  large  orifice  was  made,  and  the  blood 
allowed  to  flow  till  thirty-eight  ounces  had  escaped,  when  syncope  en- 
sued. When  half  the  above  quantity  had  passed,  the  tremor  became 
more  general  and  severe.  The  gluteal  muscles  were  so  greatly  con- 
vulsed that  by  their  action  the  patient  was  thrown  up  from  his  seat 
with  the  motion  of  a  man  sitting  on  a  trotting  horse.  When  he  became 
siik  and  faint,  the  arm  was  tied  up  and  he  was  laid  upon  a  bed.  The 
tremor  immediately  ceased,  except  some  slight  and  partial  quivering. 

He  was  then  strongly  purged,  and  this  operation  was  continued 
every  night.  On  the  5th,  at  11  A.  M.,  the  tremor  returned.  Cold  efi'u- 
sion  was  directed  ;  as  soon  as  the  cold  water  was  thrown  over  him  the 
tremor  ceased. 

On  the  9th  there  had  been  no  return  of  the  tremor.  Calomel  and 
sulphate  of  magnesia  m  re  now  prescribed  and  on  the  11th  the  tremor 
returned,  lasting,  however,  but  about  twenty  minutes.  From  this  time 
he  was  free  from  the  affection,  but,  as  might  have  been  expected,  when 
the  character  of  the  treatment  is  considered,  ho  fell  into  a  state  of  d  - 


700  CEREBROSPINAL   DISEASES. 

bility.  There  were  loss  of  appetite,  cough,  expectoration,  and  inflam- 
mation of  the  vein,  ensuing  from  the  bleeding. 

In  the  next  case  the  paroxysms  of  tremor  were  the  most  remarkable 
feature,  but  there  were  also  stupor  and  delirium. 

John  Jones,  a  seafaring  man,  aged  twenty-five,  was  brought  to  the 
hospital  March  11,  1819,  under  a  warrant  of  lunacy  ;  was  in  the  habit 
of  drinking  spirituous  liquors.  Three  weeks  previously  he  was  seized 
with  rigors,  attended  with  coldness,  and  followed  by  heat,  headache, 
and  wandering  pains  in  the  limbs.  The  symptoms  ushered  in  a  state  of 
stupor  and  delirium,  during  which  his  countenance  became  distorted, 
the  eyes  rolled,  the  muscles  of  the  face  were  slightly  convulsed,  and 
the  body  was  generally  agitated.  After  a  time  all  these  symptoms 
subsided  and  he  became  perfectly  rational,  hut  seemed  a  little  stupid,  as 
if  roused  from  a  sleep.  The  paroxysms  returned  at  uncertain  intervals 
and  with  the  same  succession  of  symptoms.  He  was  bled  and  purged, 
and  finally  brought  to  the  hospital. 

On  admission  he  was  in  a  state  of  delirium.  He  rolled  his  head 
about  and  was  in  constant  motion.  The  temporal  arteries  beat  rapidly 
and  forcibly;  the  scalp  was  hot,  the  feet  cold;  face  flushed  and  tongue 
a  little  furred. 

His  head  was  shaved  and  covered  with  cold  wet  pads,  his  feet  were 
immersed  in  hot  water,  twenty  leeches  were  then  applied  to  the  head, 
and  calomel  and  tartar-emetic  with  cathartic  draught  administered. 

The  next  day  he  was  rational,  but,  as  he  complained  of  pain  in  the 
head  and  in  the  region  of  the  liver,  and  as  his  pulse  was  130,  full  and 
jerking,  he  was  bled  to  the  extent  of  eight  ounces  ;  syncope  followed. 
Twelve  leeches  and  a  blister  were  then  applied  to  the  right  hypo- 
chondriac region,  and  calomel,  cathartic  draught,  and  low  diet  ordered. 

Notwithstanding  the  treatment,  he  continued  to  survive,  and  in  the 
evening  had  two  returns  of  the  tremor  followed  by  the  usual  symptoms. 

On  the  14th  had  several  paroxysms,  and  was  again  freely  purged  ; 
was  occasionally  bled  from  the  temporal  artery,  and  often  leeched  freely. 
Nitrate  of  silver  was  subsequently  administered,  and  on  the  23d  of  June 
he  was  discharged  cured. 

Dr.  Pritchard  states  that  he  met  with  two  other  instances  of  parox- 
ysms of  tremor  unaccompanied  with  spasm,  and  occurring  in  persons 
who  had  suffered  from  an  attack  of  paralysis. 

Evidently  Dr.  Pritchard  has  embraced  two  or  three  separate  affec- 
tions under  the  designation  of  convulsive  tremor.  The  first  case  I  have 
quoted  from  him  appears  to  be  a  distinct  and  not  previously-described 
disorder ;  the  second  case  was  probably  one  of  cerebral  congestion  or 
aborted  epilepsy;  and  those  which  he  states  he  had  seen  as  the  sequence 
of  paralysis  were  doubtless  to  be  classed  under  some  one  or  other  of  the 
forms  of  sclerosis  of  the  brain  and  spinal  cord.  The  first  case  alone  is 
to  be  regarded  as  one  of  convulsive  tremor,  as  described  in  this  chapter. 


CONVULSIVE  TREMOR.  701 

In  his  very  excellent  treatise  on  the  shaking-palsy,  Parkinson,1  in 
calling  attention  to  the  fact  that  several  diseases  characterized  by  tre- 
mor have  been  confounded  with  paralysis  agitans,  quotes  the  following 
case  from  Dr.  Kirkland  : 

"  Mary  Ford,  of  a  sanguineous  and  robust  constitution,  had  an  invol- 
untary motion  of  her  right  arm,  occasioned  by  a  fright,  which  first 
brought  on  convulsion-fits  and  most  excruciating  pain  in  the  stomach, 
which  vanished  on  a  sudden,  and  her  right  arm  was  instantaneously 
flung  into  an  involuntary  and  perpetual  motion  like  the  swing  of  a  pen- 
dulum, raising  the  hand  at  every  vibration  higher  than  the  head  ;  but, 
if  by  any  means  whatever  it  was  stopped,  the  pain  in  her  stomach  came 
on  again,  and  convulsion-6ts  were  the  certain  consequence,  which  went 
off  when  the  vibration  of  her  hand  returned." 

Parkinson  also  quotes  another  case  from  the  same  source,  resulting 
apparently  from  worms,  and  which  is  thus  described  : 

"  A  poor  boy,  about  twelve  or  thirteen  years  of  age,  was  seized  with 
a  shaking-palsy.  His  legs  became  useless,  and,  together  with  his  head 
and  hands,  were  in  continual  agitation  ;  after  many  weeks'  trial  of  va- 
rious remedies,  my  assistance  was  desired.  His  bowels  being  cleared,  I 
ordered  him  a  grain  of  opium  a  day  in  the  gum-pill  ;  and  in  three  or  four 
days  the  shaking  had  nearly  left  him.  By  pursuing  this  plan,  the  medi- 
cine proving  a  vermifuge,  he  could  soon  walk,  and  was  restored  to  per- 
fect health. 

Toulmouche,3  in  a  paper  which  is  Very  suggestive  in  the  light  of  re- 
cent contributions  to  neurological  pathology,  cites  a  case  which  was 
evidently  one  of  convulsive  tremor  : 

"A  woman,  whose  respiration  was  convulsive,  presented  from  time 
to  time  the  following  condition  :  Her  nostrils  were  strongly  dilated,  the 
angles  of  the  mouth  drawn  down,  the  shoulders  and  chest  spasmodical- 
ly elevated,  the  inspiration  strong  and  deep,  the  sterno-cleido-mastoid 
muscles  were  powerfully  contracted.  During  these  paroxysms,  which 
lasted  several  minutes,  the  patient  was  deprived  of  the  faculty  of  speech 
and  threatened  with  suffocation.  Nevertheless,  she  could,  if  so  direct- 
ed, move  the  head,  the  shoulders,  and  the  muscles  of  the  face,  although 
the  spasm  continued.  .  .  .  In  another  case  the  affection  was  almost  en- 
tirely confined  to  the  sterno-cleido-mastoid  muscle.  The  patient  could 
turn  the  head  in  either  direction,  but  gradually  it  moved  from  righl  to 
left,  without  Ipt  ability  to  control  its  action,  so  that  the  right  ear  al- 
most rested  upon  the  sternum.  The  other  muscles  of  the  shoulder  con- 
tracted at  the  same  time.  He  likewise  reports  another  case  in  which 
the  head  was  almost  continually  in  motion,  the  patienl  executing  twen- 

1  "Es-ay  on  the  Bhaking-Palsy,"  London,  1817,  p.  2'.>. 

•  "  Observation*  de  qoelquea  fonctionB  Involontairea  dee  appareUs  de  la  locomotion, 
et  dc  la  prehension,"  "Memoires  do  l'acadomir  royale  de  m6dedne,"  tome  deui 

Paris,  1838. 


702  CEREBROSPINAL   DISEASES. 

ty-two  rotations  in  a  minute  ;  the  movement  was  due  to  the  alternate 
contraction  of  the  sterno-cleido-mastoid  and  splenius  muscles  of  each 
side  ;  respiration  was  not  obstructed.  The  movements  diminished  and 
finally  ceased  after  two  or  three  attacks  of  haemoptysis. 

"  The  conclusions  which  the  author  draws  from  his  own  cases,  and 
those  which  he  cites  from  other  authorities,  are  mainly  interesting  in 
relation  to  his  theory  of  the  pathology.     They  are — 

"  1.  That  there  exist,  for  the  movements  of  the  different  groups  of 
muscles,  different  central  motor  forces. 

"  2.  That  the  cerebellum  only  presides  over  the  coordination  of  those 
complex  movements  which  are  necessary  to  the  different  acts  of  stand- 
ing and  locomotion,  and  not  at  all  over  those  that  regulate  the  more  sim- 
ple movements  of  the  trunk  and  the  members. 

"3.  That  this  nerve-centre  supplies  to  vertebrate  animals  the  power 
to  maintain  themselves  in  equilibrium  and  to  exercise  locomotion. 

"1.  That,  if,  in  the  species  of  neurosis  I  have  described,  the  sensa- 
tion and  the  intellectual  faculties  experience  no  change,  this  fact  is  due 
to  the  circumstance  that  the  lesions  of  the  cerebellum  have  not  yet  in- 
volved the  tubercula  quadrigemina.  That  these  last-named  organs  are 
in  a  state  of  dependence  upon  the  brain  ;  since  in  the  normal  state  ani- 
mals move  through  the  impulsion  of  various  motives  of  which  the  brain 
is  the  seat. 

"  5.  That  finally  a  number  of  affections  called  nervous,  consisting  in 
the  most  erratic  derangements  of  the  muscular  functions,  such  as  an 
irresistible  tendency  to  go  backward  or  to  advance  without  rational 
motive,  to  leap,  to  perform  other  disorderly  movements,  constitute  only 
a  species  of  insanity  or  aberration  of  the  locomotor  functions  depend- 
ing on  an  affection  either  organic  or  functional  of  the  cerebellum." 

I  have  quoted  the  conclusions  of  Toulmouche  in  full  more  as  evi- 
dence of  the  fact  that  he  was  disposed  to  locate  the  seat  of  these  trou- 
bles in  the  cerebellum,  than  as  intending  to  endorse  'his  collateral 
hypotheses.  At  one  time  I  also  held  the  opinion  that  the  seat  of  con- 
vulsive tremor  was  in  the  cerebellum,  but  I  have  for  some  time  had  a 
different  idea  on  the  subject. 

Up  to  the  publication  of  my  own  paper,  in  1867,  there  had  been  no 
attempt  made  to  define  accurately  the  features  of  the  disease  under  no- 
tice. My  description  of  the  affection  was  based  upon  three  cases.  They 
were  as  follows  : 

Case  I. — J.  S.,  a  gentleman,  aged  thirty-five,  single,  and  engaged 
in  mercantile  pursuits,  consulted  me  on  March,  14,  1867,  for  an  affec- 
tion which,  as  he  said,  "was  driving  him  mad."  Ordinarily  he  had 
nothing  to  complain  of  on  the  score  of  health.  His  appetite  was  good, 
and  all  his  functions  were  performed  with  regularity  ;  but  two  or  three 
times  during  the  course  of  the  day  he  would  be  seized  with  severe  and 
uncontrollable  muscular  tremor,  involving  his  head  and  all  the  muscles 


CONVULSIVE   TREMOR.  703 

of  the  trunk  and  arms.  At  the  same  time  there  would  be  neadache  and 
an  intense  feeling  of  anxiety.  There  was  no  loss  of  consciousness,  not 
even  for  an  instant,  or  inability  to  walk  or  to  direct  any  muscle,  and  no 
confusion  of  thought.  After  the  paroxysm  had  lasted  fifteen  or  twenty 
minutes  it  gradually  passed  off,  leaving  him  in  a  profuse  perspira- 
tion. 

While  he  was  sitting  in  my  library  an  attack  came  on.  He  was 
seized  with  as  much  suddenness  as  though  he  were  struck  with  an  epi- 
leptic fit.  His  head  shook  violently,  the  muscles  of  his  face  were  con- 
vulsed, his  arms  and  hands  trembled,  and  his  gluteal  muscles  contracted 
so  powerfully  as  to  cause  him  to  move  convulsively  up  and  down  on  his 
chair.  His  lower  extremities  were  altogether  free  from  spasm  or  con- 
vulsion. Upon  putting  my  hand  on  his  wrist,  I  found  that  every  ten- 
don was  in  action,  and  in  the  arm,  hand,  neck,  and  face,  the  vibration 
of  the  muscular  fibres  could  be  distinctly  seen  and  felt.  I  thought  the 
action  was  greater  on  the  left  than  on  the  right  side. 

The  thermometer  applied  to  the  axilla  marked  101°  Fahr.,  and  the 
sesthesiometer  showed  an  increased  sensibility  of  the  skin  of  the  face, 
neck,  hands,  and  all  the  upper  parts  of  the  body  I  examined.  The  res- 
piration was  quickened,  and  the  pulse  was  increased  from  80  to  95  per 
minute. 

During  the  continuance  of  the  paroxysm  he  conversed  rationally 
but  with  some  difficulty,  owing  to  the  action  of  the  muscles  of  the  neck, 
mouth,  and  chest.  The  pupils  contracted  briskly  under  the  influence 
of  light,  and  dilated  when  it  was  shut  off.  Several  times  he  rose  from 
his  chair  and  paced  the  room;  his  movements  were  perfectly  well  made. 
There  was  a  little  headache,  confined  to  the  occipital  region,  and  a  slight 
but  persistent  vertigo. 

1  desired  him  to  perform  a  few  movements  with  his  hands,  such  as 
buttoning  his  waistcoat.  He  had  no  great  difficulty  in  carrying  his 
hands  to  the  buttons,  but  it  was  impossible  for  him  to  seize  them,  and 
the  more  his  efforts  were  directed  to  this  end  the  more  difficult  it  was  for 
him  to  accomplish  it.  The  trouble  was  not  in  loss  of  strength,  for,  when  I 
I  liitn  to  grasp  my  hand,  he  did  it  with  great  force,  but  the  tremor 
was  so  constant  that  he  could  not  keep  the  ends  of  his  fingers  at  any 
one  point. 

After  tip'  paroxysm  had  lasted  about  fifteen  minutes  it  began  to 
subside,  and  in  ten  minutes  more  had  entirely  passed  away;  The  ther- 
mometer in  tin-  axilla  now  marked  but  08°  Fahr.,  and  the  hyperesthesia 
had  entirely  disappeared,  leaving  the  sensibility  of  the  skin  natural. 
The  respiration  and  pulse  l><>camc  normal  in  frequency 

i  questioning  tins  gentleman,   I  ascertained  that  he  had   in- 

less  in  venereal  pleasures,  and  that  the  first   attack  <>f 

tremor  had  begun  during  sexual  intercourse.     Be  said  that,  jusl  as  the 

orgasm  was  approaching  its  height,  he  had  experienced  a  Bevere  pain 


704  CEREBRO-SPINAL   DISEASES. 

in  the  back  of  his  head,  accompanied  with  tremor.  That,  notwith- 
standing, he  had  completed  the  act,  but  felt  very  greatly  debilitated 
after  it;  the  tremor  continued  for  a  few  minutes,  and  then  passed  off. 
This  was  about  four  months  before  I  saw  him.  Since  the  beginning  of 
his  disease  he  had  entirely  abstained  from  all  sexual  indulgence,  but  his 
tremors  had  not  left  him  for  a  night  or  day.  In  consequence  he  was 
low-spirited,  and  apprehensive  of  losing  his  reason. 

Case  II. — The  second  case  was  that  of  a  young  lady,  aged  twenty- 
one,  who  was  sent  to  me  March  21,  1867,  by  Dr.  C.  F.  Taylor,  to  whom 
she  had  gone  to  be  treated  for  lateral  curvature  of  the  spine.  In  addition 
to  this  trouble  she  had  for  four  years  been  afflicted  with  a  disorder,  cer- 
tainly very  singular  in  its  characteristics,  and  for  which  she  had  been 
treated  by  many  physicians  of  many  systems  of  practice.  The  chief 
and  most  distressing  feature  was  a  spasmodic  action  of  the  diaphragm 
coming  on  every  ten  or  fifteen  minutes,  producing  convulsive  respira- 
tion, a  feeling  of  impending  suffocation,  and  great  mental  anxiety. 
The  paroxysms  lasted  four  or  five  minutes,  and  then  passed  off  with  a 
long,  deep-drawn  sigh.  None  of  the  respiratory  muscles  but  the  dia- 
phragm were  convulsed.  By  placing  the  hands  over  the  abdomen  this 
muscle  could  be  distinctly  felt  in  a  state  of  rapid  and  irregular  action. 
In  the  intervals  of  the  diaphragmatic  paroxysms,  there  were  frequent 
tremors  of  the  arms,  legs,  and  head.  There  was  almost  constant  head- 
ache extending  across  the  crown  to  the  cerebellar  region.  There  was 
no  fever  or  increased  temperature,  but  great  hyperassthesia  of  the 
whole  surface  of  the  body.  The  menstrual  function  was  normal  in 
every  respect,  and  there  was  no  evidence  of  hysteria.  Her  appetite 
was  bad,  and  what  she  did  eat  was  not  of  a  very  nutritious  character. 
Occasionally  she  was  subject  to  fits  of  great  mental  and  muscular  ex- 
citement, during  which  she  fought  and  bit  all  who  came  near  her,  bat 
there  was  no  mental  aberration.  She  had  never  been  subject  to  inter- 
mittent fever. 

In  this  case  the  convulsive  tremor,  though  more  prominently  mani- 
fested in  the  diaphragm,  was  not  confined  to  this  muscle,  for,  as  I  have 
stated,  when  it  was  quiet  the  muscles  of  other  parts  of  the  body  were 
in  irregular  but  rapid  action.  There  was  not  the  entire  cessation  of 
tremor  as  exhibited  in  the  first  case,  and  the  paroxysms  were  much  less 
uniform  and  much  less  extensive  in  their  character.  In  both  cases  the 
tremor  was  absent  during  sleep. 

Case  III. — In  a  third  case  the  patient  was  a  young  man  aged  twenty- 
five,  and  a  clerk  by  occupation.  He  came  under  my  care  April  2, 1867, 
to  be  treated  for  obstinate  headaches,  with  which  he  had  been  affected 
for  several  years.  On  an  average  he  had  an  attack  twice  a  week  of  so 
Bevere  a  character  as  to  unfit  him  for  all  occupation  and  to  confine  him 
to  bed.  The  pain  was  limited  to  the  back  part  of  the  head,  and  was 
exceedingly  sharp  and  lancinating;  vertigo  and  an  indescribable  twist- 


CONVULSIVE  TREMOR.  705 

ing  sensation  within  the  cranium  accompanied  the  attack.  In  addition 
there  was  convulsive  tremor  of  the  muscles  of  the  head,  face,  and  neck, 
occurring  in  paroxysms  at  intervals  while  the  headache  lasted.  There 
was  no  loss  of  consciousness  and  no  confusion  of  thought.  There  were, 
however,  great  physical  prostration,  and  an  indisposition  to  make  any 
mental  exertion. 

In  his  youth  he  had,  as  he  informed  me,  practised  masturbation  to 
excess,  and  since  attaining  to  manhood  had  indulged  freely  with  women. 
He  was  also  addicted  to  the  abuse  of  alcoholic  liquors.  He  was  thin, 
pale,  and  of  deficient  vital  power.  His  digestive  system  was  deranged, 
his  appetite  bad,  his  pulse  weak  and  frequent.  There  was  no  disease 
of  the  lungs  or  heart.  He  had  had  gonorrhoea  and  stricture,  but  had 
never  contracted  a  chancre. 

He  had  been  under  the  charge  of  several  physicians,  but  had  never 
been  able  to  subject  himself  to  the  regimen  and  restrictions  in  his 
habits  of  life  which  they  recommended.  Latterly  he  had  undertaken  to 
treat  himself,  and  had  done  so  mainly  by  inhalation  of  chloroform. 

This  patient  would  not  abstain  from  debauchery  of  all  kinds,  and  I 
dismissed  him. 

Case  IV. — A  fourth  case  formed  the  subject  of  a  clinical  lecture 
which  I  delivered  three  years  since  before  the  class  of  the  Bellevue 
Hospital  Medical  College.  The  patient,  a  young  man,  aged  about  twen- 
ty-one, was  well  nourished,  of  general  healthy  appearance,  and  by  oc- 
cupation a  farmer. 

At  periods  varying  from  a  few  weeks  to  several  months,  he  was  sub- 
ject to  violent  convulsive  movements  in  almost  all  the  muscles  of  the 
body,  and  unattended,  except  in  one  instance,  by  loss  of  consciousness. 
The  paroxysms  lasted  several  hours,  and  during  their  continuance  the 
patient,  owing  to  the  violent  jactitations  into  which  his  limbs  were 
thrown,  was  totally  unable  to  execute  voluntary  movements.  He  was 
even  unable  to  stand  without  support,  and  could  not  guide  either  his 
hands  or  feet.  The  muscles  of  speech  were  likewise  affected,  and  he 
was  consequently  unable  to  articulate  distinctly  the  words  he  might 
attempt  to  utter.  While  all  this  was  going  on,  his  body  was  bathed  in 
cold  perspiration,  and  the  circulation  was  accelerated.  The  respiration 
v.is  increased  in  frequency,  and  there  was  well-marked  and  persistent 
pain  in  the  back  of  the  head  and  nape  of  the  neck.  He  was  very  posi- 
tive that,  ezcepl  in  the  one  instance  to  which  reference.has  been  made, 
he  had  never  lost  consciousness  during  a  paroxysm,  lmt  had  always 
been  |  I  of  his  full  reasoning  faculties. 

On    the    Occasion  of    [OSS  of    Consciousness    the  paroxysm  had  lasted 

ral  hours  ;  he  was  in  consequence  very  much  exhausted,  and  there- 
fore he  may  have  been  suffering  from  simple  syncope,  still  it  is  possible 

the  attack  in  question  was  epileptic.      When  he  came  under  my  notice, 
d  been  affected  for  about  six  years. 
16 


706  CEREBROSPINAL   DISEASES. 

As  he  described  his  paroxysms,  the  muscles  were  affected  very  much 
as  are  those  of  a  person  suffering  from  chorea  of  very  violent  charac- 
ter. 

Case  V. — A  fifth  case  was  that  of  a  man  thirty  years  of  age,  who, 
in  November,  1875,  came  to  my  clinic  for  diseases  of  the  nervous  sys- 
tem at  the  University  Medical  College.  At  intervals  through  the  day, 
as  often  ^s  twenty  or  more  times,  he  was  seized  with  violent  convulsive 
movements,  tremulous  in  character,  and  mainly  confined  to  the  muscles 
of  the  trunk,  neck,  and  upper  extremities.  As  in  the  other  cases,  there 
was  no  loss  of  consciousness,  nor  was  there  any  other  mental  disturb- 
ance. He  had  no  power  of  control  over  these  paroxysms  and  no  warn- 
ing of  their  approach.  They  were  unattended  with  disturbances  of  the 
respiration,  circulation,  or  sensibility.  The  duration  rarely  exceeded 
ten  seconds,  and  was  generally  shorter  than  this.  It  was  impossible  to 
say  where  the  convulsive  movements  originated.  They  came  more  as 
an  explosion  than  as  a  gradually-developed  action. 

While  the  convulsion  was  at  its  height,  he  could  always  cut  it  short 
and  prevent  others  for  a  time  by  smoking  a  pipe  of  tobacco,  the  requi- 
sites for  which  he  kept  constantly  ready.  He  had  been  affected  for 
seven  years,  but  had  in  that  time  experienced  an  intermission  of  about 
six  months.     He  had  never  had  a  paroxysm  while  asleep. 

Case  VI. — This  case  was  that  of  a  lady  from  Ohio,  who  consulted 
me  for  paroxysms  of  convulsive  tremor,  coming  on  several  times  in  the 
course  of  the  week,  and  involving  the  upper  and  lower  extremities  and 
neck.  There  were  also  marked  disturbances  of  the  respiration  and  cir- 
culation, and  pain  in  the  nape  of  the  neck.  The  movements  consisted 
of  rapid  but  limited  flexions  and  extensions  of  the  limbs  and  rotatory 
movements  of  the  head.  The  duration  of  a  paroxysm  was  rarely  less 
than  ten  minutes,  and  sometimes  was  several  hours.  There  was  no 
mental  disturbance  or  impairment  of  consciousness.  The  disease  had 
existed  for  several  years,  and  had  proved  unamenable  to  all  medical 
treatment.  After  each  seizure  there  was  a  very  intense  feeling  of  fa- 
tigue, but  no  tendency  to  sleep  or  stupor.  No  paroxysm  had  ever  oc- 
curred during  sleep.  The  general  health  was  excellent,  and  the  mind 
was  active  and  strong. 

Several  other  cases  similar  in  general  features  to  the  foregoing  have 
been  under  my  charge. 

From  this  history  and  description  it  will  be  seen  that  convulsive 
tremor  is  an  affection  characterized  by  paroxysms  of  clonic  convulsions 
affecting  the  voluntary  muscles  and  unattended  by  loss  of  conscious- 
ness or  by  mental  aberration,  though  sometimes  there  is  emotional  dis- 
turbance. Vertigo  and  pain  in  the  head  are  also  occasional  accompani- 
ments. 

Causes. — Nothing  very  definite  is  known  relative  to  the  etiology  of 
the  disease.     In  one  of  my  cases  it  began  during  sexual  intercourse  ; 


CONVULSIVE   TREMOR.  707 

In  another  (Case  V.)  it  ensued  immediately  after  a  sunstroke,  the  first 
paroxysm  occurring  while  the  patient  was  still  in  a  comatose  condition; 
in  another  (Case  III.),  sexual  and  alcoholic  excesses  appeared  to  be  the 
cause.  In  none  of  the  others  could  any  approach  to  a  relation  of  cause 
and  effect  be  established. 

Diagnosis. — From  epilepsy,  convulsive  tremor  is  distinguished  by 
the  absence  of  loss  of  consciousness.  Many  of  the  cases  which  Dr. 
Hughlings  Jackson  considers  epileptic  are,  in  my  opinion,  more  prop- 
erly embraced  under  the  present  category.  From  chorea  it  differs  in 
the  facts  that  the  muscular  action  is  paroxysmal  and  not  continuous, 
and  that  the  movements  are  different  in  character,  those  of  convulsive 
tremor  being  rapid  and  tremulous,  while  those  of  chorea  are  slower  and 
more  systematic.  The  paroxysmal  nature  of  the  actions  serves  to  dis- 
tinguish it  from  athetosis,  multiple  cerebral  sclerosis,  multiple  cerebro- 
spinal sclerosis,  and  paralysis  agitans.  From  hysteria  it  is  in  uncom- 
plicated cases  diagnosticated  by  the  absence  of  other  symptoms  of  the 
hysterical  condition,  by  the  fact  that  the  convulsions  are  not  marked 
by  tonic  spasms,  and  the  circumstance  that  they  have  for  each  individual 
case  a  definite  character. 

Prognosis. — The  prognosis  is  generally  favorable,  the  disease,  in  my 
experience,  being  quite  amenable  to  medical  treatment.  All  the  cases 
under  my  care  recovered  except  one  in  which  the  patient  refused  to 
submit  to  proper  hygienic  restraints,  and  in  whom  treatment  was  not 
therefore  systematically  pursued. 

Morbid  Anatomy  and  Pathology. — In  former  papers  I  have  stated 
my  belief  that  convulsive  tremor  was  an  affection  of  the  cerebellum, 
but  in  the  licdit  of  the  investigations  of  Fritsch  and  Hitzig;  Nothna<?el, 
Fender,  and  Bartholow,  lam  now  disposed  to  consider  it  due  to  irrita- 
tion of  nerve-centres  in  the  cortical  substance  of  the  cerebrum,  con- 
joined with  a  hypenesthetic  condition  of  the  medulla  oblongata  and 
upper  part  of  the  spinal  cord.  And  I  am  the  more  confirmed  in  this 
opinion  by  some  recent  experiments  by  which  I  have  ascertained  that 
a  very  similar  disorder  can  be  induced  in  dogs  by  the  faradization  of 
the  parts  mentioned. 

I  ;cr '  produced  epileptiform  convulsions  in  rabbits  by  faradizing 
the  greater  part  of  a  hemisphere.  In  one  of  my  own  experiments  I 
exposed  both  hemispheres  and  applied  to  each  a  piece  of  chamois-skin 
thoroughly  moistened  with  water,  and  cut  to  fit  the  surface.  The 
elect  rodea  —metallic  buttons — wen-,  then  placed oncon  each  piece  of  oha» 
mois-skin,  and  moved  lightly  over  the  surfaces  for  a  few  Beconds.  The 
animal  was  (hen  allowed  to  emerge  from  the  anaesthetic  condition,  and 
immediately  general  convulsive  movements  ensued  without  loss  of 
The    result  was,  therefore,  similar  to  that  obtained  by 

l-u Experimental  Researches  in  Cerebral  Physiology  and  Pathology,"  "Wert  Riding 
Lunatic  Asylum  Medical  Reports,"  vol.  iii.,  1873,  p.  30. 


708  CEREBROSPINAL   DISEASES. 

Ferrier,  but  so  far  as  I  can  judge  the  convulsive  movements  -were  more 
general,  and  there  was  no  pleurothotonos  as  in  his  cases.  The  parox- 
ysm lasted  about  ten  seconds,  and  was  repeated,  though  n<  >t  to  the  same 
degree  of  intensity,  after  an  interval  of  three  minutes.  During  the 
next  half -hour  there  were  repeated  localized  convulsive  movements  in 
various  parts  of  the  body. 

In  another  dog  I  exposed  both  hemispheres,  and  also  the  upper  part 
of  the  spinal  cord,  as  far  down  as  the  fourth  cervical  vertebra.  A  piece 
of  wet  chamois-shin  was  then  laid  upon  the  brain,  and  one  electrode — a 
thin  plate  of  copper — placed  in  contact  with  it,  while  the  other — a  thin 
copper  wire  doubled  upon  itself — was  moved  up  and  down  upon  the 
exposed  spinal  cord.  During  this  operation  the  animal  was  in  a 
state  of  general  convulsion,  the  respiratory  muscles,  especially  the  dia- 
phragm, being  involved.  The  current  was  passed  in  this  manner  for 
ten  seconds.  The  animal  was  then  allowed  to  recover  consciousness. 
As  soon  as  the  effects  of  ether  had  measurably  passed  off,  convulsive 
movements  ensued  throughout  the  body,  the  diaphragm  being  marked- 
ly affected  with  the  other  respiratory  muscles,  and  the  heart  beating 
with  great  irregularity,  both  in  regard  to  force  and  rhythm. 

In  these  experiments  a  Gaiffe's  faradaic  machine  was  employed,  and 
the  current  was  so  feeble  as  barely  to  move  the  hammer  and  to  be  felt 
when  the  electrodes  were  applied  to  the  tongue. 

I  think  with  Dr.  Hughlings  Jackson  that  such  convulsive  movements 
are  the  result  of  "  discharging  lesions  "  of  nerve-centres.  The  case  of 
the  patient  to  which  I  have  referred  under  the  head  of  epilepsy,  in 
whom  there  was  convulsive  tremor  of  one  side  of  the  neck  and  face, 
induced  by  irritation  applied  to  the  skin  of  that  side,  shows,  as  well  as 
others  on  record,  that  such  instances  may  be  developed  into  epilepsy 
under  adequate  circumstances,  but,  as  there  said,  I  cannot  regard  them 
as  primarily  epileptic. 

In  another  case — that  of  a  young  lady  who  has  come  under  my  care 
since  the  chapter  on  epilepsy  was  written,  who  is  very  excitable,  has 
had  two  choreic  periods,  and  once,  certainly,  an  epileptic  seizure — there 
are  daily  several  attacks  of  convulsive  tremor,  in  which  the  action 
starts  from  the  right  side  of  the  neck,  gradually  invades  the  right  side 
of  the  face,  and  eventually  the  muscles  of  the  corresponding  upper 
extremity.  There  is  not  for  a  moment  the  slightest  impairment  of  con- 
sciousness. The  face,  however,  is  at  first  deathly  pale,  but  soon  be- 
comes flushed.  There  is  no  stupor,  no  mental  confusion  before,  during, 
or  after  the  attack.  She  laughs  and  talks  during  its  continuance,  and 
has  a  perfect  recollection  of  every  thing  that  takes  place  during  the 
paroxysm.  That  such  a  case  is  very  near  to  epilepsy  is  undoubted,  but 
then  congestion  is  very  near  to  inflammation,  and  may  exist  for  years 
without  advancing  to  full  development. 

There   are   certain   morbid  conditions  usually  classed  as    choreic, 


CONVULSIVE  TREMOR  709 

which  have  more  affinity  with  convulsive  tremor  than  with  chorea, 
though,  perhaps,  they  are,  with  even  greater  propriety,  placed  under  the 
head  of  hysteria.  These  are  the  turnings,  salaam-convulsions,  jump- 
ings,  etc.  It  is  quite  probable  that  the  lesion  causing  those  disorders 
is  similar  to  that  producing  convulsive  tremor. 

The  morbid  anatomy  of  the  affection  under  notice  is  entirely  a 
matter  of  supposition,  and  indeed  there  are  not  many  data  for  forming 
an  opinion  relative  to  the  essential  nature  of  the  structural  alteration. 
So  far  as  we  can  judge  from  a  consideration  of  the  phenomena,  the  seat 
is  in  the  cortical  substance  of  the  brain,  and  in  the  medulla  oblongata 
and  upper  part  of  the  spinal  cord.  The  disturbances  of  the  respiration 
and  circulation  point  to  these  latter  organs  as  a  part  of  the  anatomical 
substratum. 

In  those  cases  in  which  there  are  spasms  localized  in  various  parts 
of  the  face,  neck,  or  extremities,  it  is  probable  that  the  lesion  exists 
entirely  in  a  limited  part  of  the  cortical  substance  constituting  the 
motor  centre  for  the  region  involved. 

Treatment. — In  the  first  cases  that  came  under  my  observation,  I 
employed  counter-irritation  in  the  form  of  a  seton  inserted  into  the 
nape  of  the  neck,  large  doses  of  the  bromide  of  potassium,  and  the 
primary  galvanic  current.  Iron  and  quinine  were  given  in  two  cases  to 
relieve  the  general  anaemic  condition  which  existed.  These  measures 
were  entirely  successful,  except  in  the  third  case,  in  which  the  bromide 
of  potassium  produced  no  perceptible  effect.  The  tincture  of  hyoscya- 
mus  was  substituted  for  it  with  good  results,  but  all  treatment  was 
subsequently  abandoned  as  stated. 

In  the  fourth  case  the  patient  was  treated  with  gradually-increasing 
doses  of  strychnia,  with  the  effect  of  causing  a  complete  cure.  A  solu- 
tion of  the  sulphate  of  strychnia,  consisting  of  two  grains  to  the  ounce 
of  water,  was  administered  in  doses  of  ten  drops  three  times  a  day,  the 
doses  being  increased  by  one  drop  every  day,  till  the  physiological 
effects  of  the  drug  were  obtained.  A  return  to  the  original  dose  of  ten 
drops  was  then  directed,  and  an  increase  as  before.  From  thirty  to 
thirty-five  drops  were  generally  necessary  to  cause  slight  rigidity  of  the 
muscles  of  the  legs  and  neck.  The  patient  continued  treatment  for 
several  months,  and  had  no  further  spasms. 

In  the  fifth,  sixth,  and  other  cases,  I  have  relied  for  internal  treat- 
ment entirely  on  the  bromide  of  zinc  given  in  solution  in  gradually- 
increasing  doses.  In  all  of  these  the  result  has  boon  entirely  satisfac- 
tory^ In  the  fifth  case,  no  paroxysm  ensued  after  the  first  day  of  treat- 
ment. Font  weeks  afterward,  the  patient  presented  himself  at  my 
clinic,  and  announoed  the  complete  cessation  of  all  convulsive  move- 
ments, and  that  he  had  resumed  his  work,  which  had  been  interrupted 
for  several  years. 

In  the  sixth  case  I  administered  the  zinc,  and  in  addition  applied 


710  CEREBROSPINAL   DISEASES. 

the  actual  cautery  repeatedly  to  the  nape  of  the  neck.  Only  one 
paroxysm  occurred  after  the  treatment  was  begun,  and  tnat  was  in- 
duced by  the  excitement  and  irritation  caused  by  the  primary  galvanic 
current  applied  to  the  spine.  The  patient,  two  months  afterward,  re- 
mained entirely  well,  though  still  continuing  to  take  the  zinc. 

In  all  the  other  cases,  five  in  number,  the  bromide  of  zinc  has  suf- 
ficed to  effect  the  cure. 

I  have  uniformly  given  it  in  solution,  either  in  water  or  simple 
syrup,  in  the  proportion  of  one  drachm  to  the  ounce.  Of  this  mixture, 
ten  drops  were  given  three  times  a  day  for  the  first  two  weeks,  then  fif- 
teen drops  three  times  a  day  for  the  next  fortnight,  and  so  on,  increas- 
ing five  drops  for  the  doses  of  each  subsequent  two  weeks.  This  course 
has  been  continued  for  from  three  to  six  months,  and  then  the  doses 
are  gradually  reduced,  except  in  Cases  V.  and  VI.,  in  which  I  shall 
continue  them  for  a  much  longer  period,  and  in  two  others  which  have 
been  but  for  a  short  time  under  treatment. 


CHAPTER  IV. 

CHOREA. 

Although  it  is  quite  certain  that  several  distinct  affections  are  in- 
cluded under  the  term  "  chorea,"  these  are  analogous  to  each  other, 
and,  as  we  know  little  about  the  essential  anatomical  features  of  these 
disorders,  and  as  they  are  allied  by  their  symptoms,  it  will  be  advisable, 
for  the  present,  to  consider  them  together. 

Symptoms. — Even  in  simple,  typical,  and  uncomplicated  cases  of 
chorea,  the  symptoms  exhibit  great  variety.  They  are  connected 
mainly  with  the  mind,  with  motility,  and  with  sensibility,  though,  at 
the  same  time,  the  functions  of  organic  life  are  generally  more  or  less 
deranged. 

Among  the  earliest  symptoms  of  chorea  are  those  referable  to  dis- 
ordered brain-action.  The  character  and  disposition  of  the  patient 
undergo  a  marked  change,  and  there  is,  besides,  from  the  first,  a  very 
decided  impairment  of  mental  vigor.  The  emotions  are  easily  excited, 
and  the  temper  becomes  fretful  and  irritable.  Hallucinations  are  not 
uncommon,  and  these  are  generally  connected  either  with  the  sight  or 
hearing.     Sometimes  both  these  senses  are  involved. 

The  sleep  is  generally  disturbed  by  disagreeable  dreams,  sometimes 
reaching  to  the  intensity  of  nightmare,  and  these  are  so  vivid  that  the 
patient  often  considers  them  realities. 

In  a  few  cases  there  is  decided  mania,  but  this  is  not  of  a  very 
aggravated  form,  and  is  of  temporary  duration.     Three  such  instances 


CHOREA.  711 

have  recently  been  under  my  care,  all  occurring  in  young  girls  of  about 
the  age  of  puberty,  and  exhibiting  in  all  other  respects  the  typical 
characteristics  of  chorea. 

In  two  cases  under  my  observation,  the  first  notable  event  in  the 
course  of  the  disease  was  an  epileptic  paroxysm,  which,  however,  was 
not  repeated  in  either  case. 

The  most  prominent  symptoms  of  the  disease  are,  in  the  great  ma- 
jority of  cases,  exhibited  in  the  irregular  arid  disorderly  muscular  con- 
tractions which  make  their  appearance  at  a  very  early  period,  and 
which  have  given  it  a  name  in  nearly  every  language  of  the  civilized 
world.  Thus,  we  have  the  terms  chorea  (xoP£La)  a  dance),  St.  Vitus's 
dance,  St.  Guy's  dance,  etc. 

In  the  beginning  the  foot  of  one  side  drags  a  little,  and  soon  after- 
ward the  corresponding  upper  extremity  becomes  affected  with  the 
choreic  movements.  These  are  manifested  in  the  fingers,  in  the  flexion, 
extension,  and  rotation  of  the  wrist,  and  in  the  movements  of  the  elbow 
and  shoulder.  No  matter  where  the  hand  be  placed,  it  cannot  be  kept 
steady,  but  it  and  the  whole  extremity  are  in  a  constant  state  of  agita- 
tion. Before  long  the  muscles  of  the  neck  and  face  participate,  the 
head  is  jerked  from  side  to  side,  and  a  continual  series  of  grimaces  is 
the  result  of  the  actions  in  the  facial  muscles. 

In  some  cases  the  involuntary  movements  are  confined  to  one  lat- 
eral half  of  the  body,  constituting  the  form  known  as  hemichorea. 
This  is  the  case  in  about  one-fourth  of  the  instances.  Thus,  of  two  hun- 
dred and  thirty-five  cases  cited  by  S£e,'  the  phenomena  in  sixty-four 
were  limited  to  one  side.  This  limitation  has  not,  as  was  formerly 
supposed,  any  relation  with  hemiplegia,  but  is  solely  the  result  of  the 
suspension  of  the  progress  of  the  disease. 

At  first  the  movements  are  moderate,  but  they  go  on,  becoming 
more  and  more  severe,  until,  in  extreme  cases,  the  condition  of  the  pa- 
tient becomes  exceedingly  pitiable.  The  arms,  the  legs,  the  face,  and 
head,  are  in  almost  constant  action.  Every  attempt  to  perform  a  vol- 
untary movement  excites  still  more  the  disorderly  actions,  and  thus  the 
patient  is  unable  to  feed  or  dress  himself,  and  sometimes  even  walking 
becomes  impossible. 

In  one  type  of  cases  the  convulsive  movements  come  on  paroxys- 
mally,  and  are  often  of  the  most  astonishing  character.  The  patient  is, 
perhaps,  lying  quietly  on  the  bed,  when  suddenly  the  head  is  thrown 
backward,  the  limbs  Bet  in  involuntary  motion,  and  the  muscles  of  the 
trunk  contract  so  violently  as  to  throw  the  sufferer  forcibly  to  the  floor. 
Again,  a  series  of  gyratory  motions  ensues,  and  the  patient  turns 
round  on  one  foot  until  complete  exhaustion  follows  ;  or  there  may  be 

1  "  J)c  la  chor6c  ft  dee  affections  nerveuses  en  general,  aveo  lenn  rapports  avec  lei 
diatheses,  et  prindpalement  avec  le  rhenmatisme,"  "  Hem.  de  racademic  de  mddedne," 
I860,  tonic  xiv.,  p.  343,  et  »eq. 


712  CEREBRO-SPIXAL   DISEASES. 

leaps  and  contortions  of  various  kinds.  Sometimes  the  movements  are 
rhythmical.  A  lad}',  who  was  under  my  charge,  "was  suddenly  seized 
with  an  irresistible  impulse  to  bend  the  left  elbow.  The  arm  con- 
tinued in  motion  for  half  an  hour,  and  then  the  right  arm  began  a  like 
movement.  In  a  few  minutes  the  head  began  to  nod,  then  the  left 
knee  was  alternately  flexed  and  extended,  and  finally  the  right  knee 
became  similarly  affected.  For  over  an  hour  these  movements  con- 
tinued, and  then  a  regular  alternation  ensued — first  the  left  arm,  then 
the  right,  then  the  head,  next  the  left  leg,  and  finally  the  right  leg. 
These  actions  were  perfectly  timed,  and  were  all  performed  in  exactly 
ten  seconds,  as  I  ascertained  by  determinations  made  on  several  occa- 
sions. As  she  sat  in  a  chair,  or  lay  on  a  bed,  she  was  a  curious  sight. 
Though  she  was  good-tempered  with  it  all,  her  emotional  system  was 
in  a  state  of  great  exaltation.     She  recovered  in  a  few  weeks. 

Chorea  of  rhythmical  or  uniform  character  has  often  prevailed  epi- 
demically. The  most  authentic  recorded  visitation  of  the  kind  was  one 
which  occurred  at  Aix-la-Chapelle  in  1374.  This  was  in  the  form  of  a 
dancing  mania,  and  is  fully  described  by  Heckcr l  under  the  name  of  St. 
John's  dance.  The  men  and  women  subject  to  it  met  in  the  streets 
and  churches,  where  "  they  formed  circles  hand-in-hand,  and,  appearing 
to  have  lost  all  control  over  their  senses,  continued  dancing,  regardless 
of  the  by-standers,  for  hours  together  in  wild  delirium,  until  at  length 
thej7  fell  to  the  ground  in  a  state  of  exhaustion.  They  then  complained 
of  extreme  oppression,  and  groaned  as  if  in  the  agonies  of  death,  until 
they  were  swathed  in  cloths  bound  tightly  around  their  waists,  upon 
which  they  again  recovered,  and  remained  free  from  complaint  until  the 
next  attack.  This  practice  of  swathing  was  resorted  to  on  account  of 
the  tympany  which  followed  these  spasmodic  ravings,  but  the  by- 
standers frequently  relieved  patients  in  a  less  artificial  manner,  by 
thumping  and  trampling  upon  the  parts  affected.  While  dancing  they 
neither  saw  nor  heard,  being  insensible  to  external  impressions  through 
the  senses,  but  were  haunted  by  visions — their  fancies  conjuring  up 
spirits,  whose  names  they  shrieked  out  ;  and  some  of  them  afterward 
asserted  that  they  felt  as  if  they  had  been  immersed  in  a  stream  of 
blood,  which  obliged  them  to  leap  so  high.  Others,  during  the  parox- 
ysm, saw  the  heavens  open  and  the  Saviour  enthroned  with  the  Virgin 
Mary,  according  as  the  religious  notions  of  the  age  were  strangely  and 
variously  reflected  in  their  imaginations. 

In  the  most  fully-developed  and  best-marked  instances  of  the  dis- 
ease, it  was  often  ushered  in  by  an  attack  of  epileptic  convulsions. 
Such  were  probably  cases  of  hystero-opilepsy,  an  affection  to  be  pres- 
ently considered  at  greater  length. 

The  affection  spread  like  wild-fire — being  fed  by  that  principle  of 
imitation  which  appears  to  be  so  powerful  an  influence  in  causing  the 

1  "Epidemics  of  the  Middle  Ages,"  "Sydenham  Society  Translation,"  1844.  p.  87. 


cnoREA.  713 

propagation  of  this  and  analogous  disorders  of  the  nervous  system. 
Those  affected  were  generally  regarded  as  being  possessed  by  evil  de- 
mons, and  consequently  only  to  be  cured  by  the  exorcisms  of  the  clergy. 

In  1418  it  broke  out  in  Strasbourg,  and  there  received  the  name  of 
St.  Vitus's  dance,  from  the  fact  that  the  most  efficacious  means  of  cure 
was  thought  to  consist  in  the  intercession  of  this  saint. 

Similar  attacks  of  dancing  mania  had  occurred  before  that  of  St. 
John,  but  the  details  are  more  or  less  obscure,  and  several  have  occurred 
since.  Among  these  latter  must  be  placed  the  tarentism  which  overran 
Italy,  and  various  more  restricted  epidemics  of  like  disorders.  In  our 
own  country  we  have  had  the  Jumpers,  and  we  still  have  the  Shakers. 
In  addition  to  these  are  many  of  the  manifestations  of  witchcraft,  which 
were  choreic,  and  of  which  this  country  has  had  its  full  share,  and  of 
spiritualism,  which  it  enjoys  the  doubtful  honor  of  having  initiated.1 

Huntington  has  described  a  form  of  chorea  which  occurs  in  families, 
and  seems  to  be  influenced  by  heredity.  Several  instances  of  the  die- 
ease  occurring  in  one  family  have  come  under  my  observation.  It  differs 
materially  from  ordinary  chorea  in  that  it  does  not  make  its  appear- 
ance until  adult  life,  that  there  is  every  evidence  of  mental  deteriora- 
tion, and  that  the  disease  is  progressive,  and  usually  terminates  fatally. 

In  chorea,  even  of  the  ordinary  simple  kind,  the  speech  is  imperfect, 
owing  to  the  incoordination  of  the  muscles  directly  concerned  in  articu- 
lation, and  those  which  affect  respiration.  There  are,  therefore,  stutter- 
ing and  stammering,  and  at  times  a  peculiar  difficulty  of  speaking,  ow- 
ing to  the  attempt  being  made  when  the  chest  is  empty  ;  that  is,  when 
expiration  has  just  been  accomplished.  The  vocal  cords  are  sometimes 
affected,  causing  the  individual  to  utter  peculiar  sounds,  such  as  bark- 
ing, grunting,  and  sighing,  both  on  inspiration  and  on  expiration.  The 
tongue  and  lips  rarely  escape  being  involved  to  a  considerable  extent. 

The  muscles  of  mastication  and  deglutition  are  generally  affected, 
and  hence  the  food  is  imperfectly  chewed,  and  often  causes  choking 
from  difficulty  of  swallowing  it. 

In  some  cases  chorea  is  accompanied  with  paralysis — the  chorea 
paralytica  of  authors.  This  loss  of  the  power  of  voluntary  ni< «t ion  is 
usually  hemiplegia,  and  involves  the  same  muscles,  which  are  the  seal 
of  the  irregular  movements.  Occasionally  there  are  contractions  of 
the  Limbs,  hut  nut  to  any  great  degree. 

Dr.  Weir  .Mitchell  '  has  also  called  attention  to  disorderly  move- 
ments Bupervening  after  paralysis,  to  which  he  applies  the  term  of 
post-paralytic  chorea.     Tin-  propositions  which  he  enanoiates  are  : 

1.  Thai  ad  alts  who  have  had  hemiplegia,  and  who  have  entirely 
recovered,  are  often  the  subjects  of  chorea!  disorder. 

1  Set  the  author*!  "On  Certain  Causes  <>f  Nervous  Derangement,"  for  more  complete 
details  on  this  and  analogous  subjects,  and  for  accounts  of  other  examples. 

2  "Post-Paralytic  I Ihorea,"  Am.  ,-;■■.,„  ,/.,,/, ■„,/'  of  tlt>  Medic  .  I  lotober,  1814. 


714  CEREBROSPINAL  DISEASES. 

2.  That  the  younger  the  patient  the  more  apt  these  choreal  devel- 
opments are  to  ensue. 

Dr.  Mitchell  adduces  several  interesting  cases  in  support  of  these 
propositions,  and  quite  a  large  number  have  come  under  my  own  obser- 
vation. But  the  condition  in  question  is  an  entirely  different  affection 
from  athetosis,  with  which  it  has  been  frequently  confounded. 

Chorea  is  sometimes  of  very  limited  extent.  It  may  be  only  shown 
in  the  hand  or  foot,  but  more  frequently,  when  restricted  in  its  topog- 
raphy, it  is  manifested  in  the  head  or  face.  There  may  be  only  a  little 
twitching  of  the  muscles  at  the  angles  of  the  mouth,  or  of  those  which 
raise  the  upper  lip,  or  of  the  orbicularis  palpebrarum,  by  which  the 
eyelids  are  closed,  or  of  the  levator  palpebroe  superioris,  or  of  the 
corrugator  supercilii,  or  occipito-frontalis.  Sometimes  the  head  is  ro- 
tated suddenly,  or  twitched  to  one  side,  or  there  is  a  shrugging  of  the 
shoulders. 

In  several  cases  that  have  been  under  my  care,  the  abnormal  mani- 
festations were  entirely  confined  to  the  organs  of  voice  or  speech.  In 
one  instance — that  of  a  young  girl  from  Illinois — while  there  was  a 
general  hyperesthesia  of  the  whole  nervous  system,  there  were  no 
choreic  movements  except  of  the  respiratory  and  laryngeal  muscles. 
The  respiration  was  therefore  exceedingly  irregular,  and  at  times  inar- 
ticulate sounds  were  made,  which  were  involuntary.  Articulate  speech 
was  lost  from  inability  to  coordinate  the  muscles,  but  there  was  no 
paralysis,  for  the  tongue  could  be  moved  freely  in  all  directions,  and 
the  lips  were  as  mobile  as  ever,  except  when  the  patient  made  an  effort 
to  speak.  After  a  few  weeks  the  sound  from  the  larynx  was  made 
regularly  at  each  expiration.     There  were  no  sounds  during  sleep. 

In  this  case  there  was  a  strong  hysterical  element  present.  The 
affection  resisted  all  treatment,  and  finally  I  sent  the  patient  home, 
scarcely  improved  except  in  her  general  health.  One  morning  she 
awoke,  began  to  speak,  and  there  was  no  resumption  of  the  laryngeal 
sounds.     She  has  continued  well  ever  since,  now  over  two  years. 

Again,  there  may  be  an  irregular  action  of  the  muscles  of  speech, 
and  in  consequence  words  are  uttered  against  the  will  of  the  patient, 
and  often  without  any  previous  knowledge  of  what  is  going  to  be  said. 
The  language  used  is  often  of  a  profane  or  indecent  character. 
This  condition  has  been  termed  "  coprolalia."  Several  such  cases  have 
been  under  my  observation,  and  I  have  alluded  to  two  of  them  in  a  recent 
lecture1  on  chorea.  Since  then  another  remarkable  case  of  the  kind 
has  come  under  my  care.  In  this  instance  there  is  scarcely  a  minute 
during  the  day  that  the  speech  is  not  going  on,  and  this  without  the  least 
power  on  the  part  of  the  patient  to  arrest  or  direct  it.  If  he  is  asked  a 
question,  he  can  only  use  a  few  apposite  words,  the  others  being  alto- 
gether without  relation  to  the  subject  about  which  he  wishes  to  speak. 
1  Journal  of  Psychological  Medicine,  January,  1871,  p.  51. 


CHOREA.  715 

The  convulsive  movements  in  chorea  almost  invariably  stop  during 
sleep.  They  are  also  sometimes  temporarily  arrested  by  intense  men- 
tal occupation,  but  are  always  rendered  worse  by  emotional  disturbance 
or  physical  fatigue.  On  the  contrary,  they  are  diminished  by  mental 
and  emotional  quietude. 

Strange  as  it  may  appear,  the  sensation  of  being  tired  is  scarcely 
ever  experienced  by  choreic  patients.  Generally  there  are  wandering 
pains  in  the  limbs,  headache,  and  pain  in  the  back.  The  cutaneous 
sensibility  is  usually  increased,  but  in  some  cases  it  is  greatly  lessened, 
and  may  be  abolished  altogether  in  some  parts  of  the  body. 

The  functions  of  the  several  viscera  are  ordinarily  more  or  less  de- 
ranged. There  are  paroxysms  of  palpitation  of  the  heart,  and  the 
action  of  this  organ  is  to  some  extent  irregular  during  the  whole  course 
of  the  disease.  Endocardial  murmurs  are  often  present,  either  systolic 
or  diastolic,  but  are  the  result  of  the  anaemia  which  is  so  prominent  a 
feature  of  chorea.  Respiration  is  imperfect ;  the  stomach  does  not 
digest  well  ;  and  there  arc  nausea  and  vomiting.  The  bowels  are  con- 
st ipated  ;  the  urine  is  loaded  with  phosphates,  and  is  of  diminished 
quantity  ;  and  the  menstrual  function  in  girls  is  imperfectly  performed, 
either  as  regards  quantity  or  quality.  The  skin  is  dry  and  harsh,  the 
hair  loses  its  gloss,  the  complexion  is  pale,  the  lips  bloodless,  the 
pupils  dilated,  and  the  sclerotic  coat  of  the  eye  of  more  than  normal 
whiteness. 

The  tendency  of  chorea  is  to  increase  to  a  certain  point,  and  then 
to  gradually  diminish.  In  favorable  cases  occurring  in  children,  it  runs 
its  course  in  about  three  months.  This  period  can  be  materially  short- 
ened by  appropriate  treatment.  Sometimes  it  ceases  very  suddenly, 
and  in  others  passes  into  a  chronic  condition,  which  may  last  for  years 
or  during  the  life  of  the  patient.  Occasionally  it  terminates  in  death, 
either  directly  or  in  consequence  of  the  supervention  of  some  inter- 
current affection.  Three  fatal  cases  have  come  under  my  observation. 
One  of  these  I  saw  several  times  in  consultation  with  my  friend  Dr.  T. 
<i.  Thomas.  The  patient  was  a  young  lady  about  twenty  years  of  age, 
an<l  her  paroxysms  were  of  the  most  violent  character,  sometimes  being 
80  Btrong  as  to  cause  her  to  throw  herself  oil  the  bed,  or  to  dash  about 
the  room  with  great  force.  No  treatment  appeared  to  exercise  any  re- 
straining effect,  and,  after  about  two  years,  she  died  of  an  abdominal 
affection.  There  was  no  post-mortem  examination.  In  the  other  two 
death  ensued  from  exhaustion. 

Relapses  are  common  in  chorea,  especially  in  children,  and  some- 
times as  many  a-~  half  a  dozen  attacks  OCCUT.      Subsequent   seizure 

usually  lese  Bevere  than  the  tirst. 

Chorea  is  often  complicated  with  hysteria — a  combination  which 

will    be    described    hereafter.      It    may    also   exist    in    conjunction    with 

rheumatism  and  malarial  fevers,  and  the  exanthemata. 


71 G  CEREBROSPINAL   DISEASES. 

In  an  interesting  monograph,  Dr.  Gowers '  gives  the  results  of  his 
studies  and  investigations  relative  to  certain  features  of  the  choreic 
condition.  He  found  that  the  electric  excitability  of  both  nerves  and 
muscles  on  the  affected  side  in  cases  of  hemichorea  is  increased  in  most 
cases  after  the  lapse  of  a  few  weeks  ;  that  there  is  no  necessary  rela- 
tion between  the  spontaneous  spasmodic  movements  of  the  affected 
muscles  and  the  incoordination  which  takes  place  when  voluntary 
movements  are  attempted ;  that  there  is  no  regularity  about  the  dis- 
tribution of  the  disorderly  movements  in  cases  of  hemichorea,  and  that 
there  appears  to  be  a  relation  in  some  cases  of  chorea  with  other  con- 
vulsive affections,  such  as  hysterical  and  epileptoid  seizures  of  various 
kinds,  and  even  true  epilepsy.  As  Dr.  Gowers  observes,  this  relation, 
the  existence  of  which  is  unquestionable,  points  in  some  cases  to  a  com- 
mon origin  ;  in  others,  to  a  predisposition  excited  by  the  one  disease. 

Causes. — Chief  among  the  predisposing  causes  of  chorea  is  age.  It 
is  more  frequent  during  the  period  extending  from  six  to  fifteen  years 
than  during  all  the  rest  of  life.  See,  of  five  hundred  and  thirty-one 
cases,  found  four  hundred  and  fifty-three  of  ages  ranging  from  six  to 
fifteen  years. 

During  the  last  ten  years,  in  my  hospital  and  private  practice  and 
at  my  clinics,  many  cases  of  chorea  have  come  under  my  observation 
and  treatment,  but  I  have  kept  no  systematic  account  of  them  since 
the  first  edition  of  this  work  was  published  (1871).  At  that  time  I 
had  full  notes  of  eighty-two  cases  ;  of  these,  sixty-seven  were  of  ages 
between  six  and  fifteen  years.  Under  the  age  of  six,  the  disease  is  less 
frequent  as  we  go  toward  birth.  Cases  have  been  met  wTith  in  infants 
at  the  breast  of  six  months  old.  The  youngest  case  I  have  had  was  a 
girl  of  eighteen  months. 

After  fifteen,  the  disease,  unless  it  occurs  as  an  epidemic,  is  not 
very  common.  Cases  are,  however,  met  with  in  adults,  and  even  in 
very  old  persons.  I  have  seen  four  cases  in  individuals  over  thirty,  and 
three  in  persons  between  the  ages  of  twenty  and  thirty.  Of  course,  I 
refer  to  the  origination  of  the  disease  at  these  ages  :  instances  of  its 
beginning  in  childhood,  becoming  chronic,  and  lasting  through  life,  are 
not  so  rare.  In  those  cases  reported  by  authors  of  the  affection  origi- 
nating very  late  in  life,  we  have  every  reason  to  conclude  that  they 
were  instances  of  organic  lesions  of  the  brain  or  spinal  cord — probably 
sclerosis — giving  rise  to  rhythmical  movements  or  paralytic  tremor. 

The  female  sex  is  much  more  liable  to  chorea  than  the  male.  Of 
See's  five  hundred  and  thirty-one  cases,  three  hundred  and  ninety-three 
were  girls  and  one  hundred  and  thirty-eight  boys. 

Of  the  eighty-two  cases  of  which  I  have  full  records,  seventy  were 
females  and  twelve  males.     Rheumatism  has  been  supposed  to  be  a 

1  "  On  some  Points  in  the  Clinical  History  of  Chorea."  Reprinted  from  the  British 
Medical  Journal,  London,  1878. 


CHOREA.  717 

predisposing  cause  of  chorea.  Of  one  hundred  and  twenty-eight  cases, 
See  found  sixty-one  in  association  with  rheumatism  ;  but  when  we  come 
to  inquire  further,  we  find  that  only  thirty-two  of  these  were  articular 
rheumatism,  while  the  rest  were  cases  in  which  there  were  wandering 
pains  which  may  have  been,  and  probably  were,  without  the  least  affin- 
ity with  true  rheumatism. 

While  it  is  certainly  the  case  that  chorea  sometimes  follows  or 
exists  (^incidentally  with  rheumatism,  I  doubt  if  its  influence  is  any 
more  than  that  of  a  depressing  agent  to  the  organism.  Of  the  eighty- 
two  cases  observed  by  myself,  only  sixteen  were  connected  with  rheu- 
matism, while  eighteen  were  just  as  intimately  related  to  other  dis- 
ease-. 

The  affection  appears  to  be  more  common  in  winter  than  in  sum- 
mer. Of  my  cases,  fifty-four  occurred  in  the  six  months  from  October 
to  March,  and  twenty-eight  in  the  other  six  months  of  the  year. 

Among  the  exciting  causes,  those  connected  with  the  emotions 
occupy  the  first  place.  Twenty-seven  of  my  cases  were  directly  the 
result  of  fright,  apprehension,  anxiety,  mental  excitement,  or  some 
other  cause  of  the  kind.  In  eight  it  was  induced  by  intense  study  at 
school,  and  in  four  from  imitating  others  similarly  affected.  This  lat- 
t<  r  fa<tor  is  not  of  so  general  application  as  in  former  times,  when 
social  life  was  different.  To  it  is,  doubtless,  to  be  ascribed  the  spread 
of  choreiform  movements  through  certain  localities,  and  especially 
convents,  such  as  occurred  in  the  thirteenth,  fourteenth,  and  fifteenth 
centuries,  to  some  of  which  reference  has  already  been  made. 

Recently  the  theory  has  been  advanced  that  eye-strain  is  a  frequent 
cause  of  chorea.  It  is  possible  that  such  a  condition  in  a  few  instances 
may  be  a  contributing  cause  in  a  person  predisposed  to  chorea,  but  in 
the  main  I  am  inclined  to  consider  such  influence  as  exceeding!  v  slight. 

Among  other  causes,  bad  hygienic  influences  and  exhausting  dis- 
easea  generally  are  to  be  mentioned. 

Pregnancy  is  also  asserted  to  be  a  cause,  and  cases  are  on  record  in 
whicli  the  futus  has  been  born  choreic  of  a  choreic  mother. 

Diagnosis. — There  is  not  much  danger  at  the  present  day  that 
chorea  will  he  confounded  with  many  of  the  diseases  from  which,  not 
long  ago,  it  was  not  clearly  disassociated.  Thus,  from  paralysis  agitans, 
epilepsy,  locomotor  ataxia,  multiple  cerebral  and  cerebrospinal  Bcle- 
r.'-i-.  the  fuller  acquaintance  which  we  have  in  recent  years  acquired 
of  these  maladies  prevents  the  necessity  of  dwelling  on  their  character- 
istics a-  distinguished  from  those  of  chorea.  The  course  of  the  latter 
disease,  and  the  symptoms,  other  than  those  connected  with  motility, 
are  in  the  others  bo  different  that  no  one  who  has  .studied  their  phe- 
nomena could  fail  in  making  a  correct  dia'_rnosi-.. 

With  hysteria,  some  of  the  forms  of  chorea  may  be  confounded, 
and  the  two  affections  are  not  infrequently  blended  in  the  same  person. 


718  CEREBRO-SPINAL   DISEASES. 

It  must  be  confessed,  too,  that  there  are  cases  in  which  the  diagnosis 
cannot  be  el  earl)-  made  out.  So  far  as  the  patient  is  concerned,  the 
difficulty  of  forming  a  correct  opinion  in  such  cases  is  not  a  matter  of 
much  moment. 

The  great  majority  of  cases  of  chorea,  such  as  are  met  with  in  chil- 
dren, are  readily  distinguished  from  hysteria.  The  facts  of  the  disease 
occurring  before  puberty  in  so  large  a  proportion  of  instances,  that  the 
emotional  system  is  rarely  disturbed  as  in  hysteria,  that  the  affection  is 
not  so  paroxysmal,  and  that  the  accessions  of  hysteria  are  more  sud- 
den, will  be  sufficient  to  render  the  diagnosis  accurate. 

From  convulsive  tremor — with  which  in  some  of  its  forms  it  is 
closely  analogous — ordinary  chorea  is  diagnosticated  by  the  facts  that 
it  is  not  paroxysmal,  but  continues  while  the  patient  is  awake,  that  the 
movements  are  more  disorderly,  while  at  the  same  time  more  purposive, 
that  the  natural  tendency  is  toward  spontaneous  recovery,  and  that  it 
usually  occurs  in  children. .  But  it  must  be  admitted  that  it  is  difficult 
to  determine  to  which  disease  certain  rhythmical  and  paroxysmal  dis- 
orders are  to  be  ascribed.  It  would  perhaps  be  more  correct  to  place 
all  such  under  the  head  of  convulsive  tremor  or  hysteria,  with  which 
affections  they  are  certainly  closely  allied. 

Prognosis. — This  is  usually  favorable  in  those  cases  which  occur 
before  puberty.  The  chorea  of  adults  is,  however,  in  most  instances,  a 
very  unmanageable  affection,  and  generally  either  terminates  in  death 
or  becomes  permanent.  Cases  in  which  death  has  ensued  have  been 
reported  by  various  authors — among  them,  Dr.  John  W.  Ogle,1  Dr.  J. 
Ilughlings  Jackson,2  and  Dr.  G.  See.3  As  already  stated,  three  fatal 
cases  have  occurred  in  my  own  experience.  The  tendency,  however, 
in  the  chorea  of  young  persons  is  decidedly  toward  recovery,  even 
under  unfavorable  circumstances  as  regards  hygiene  or  medical  treat- 
ment. 

Morbid  Anatomy  and  Pathology. — In  many  cases  of  persons  dying, 
either  from  chorea  or  from  intercurrent  affection,  no  changes  have  been 
found  which  could,  with  probability,  be  regarded  as  constituting  the 
disease.  In  other  cases,  morbid  alterations  from  the  healthy  state  have 
been  found.  The  idea  has  therefore  prevailed  that  there  are  two 
kinds  of  chorea — one  which  is  entirely  functional,  belonging  to  the  so- 
called  neuroses,  the  other  the  result  of  organic  disease  of  the  brain  or 
spinal  cord,  or  both.  In  Ogle's  sixteen  fatal  cases,  congestion  of  the 
brain  and  its  membranes  was  found  in  some,  while  in  others  the  dis- 
ease existed  in  the  spinal  cord. 

'"Remarks  on  Chorea  Sancti  Viii,  including  the  History,  Course,  and  Termination 
of  Sixteen  Fatal  Cases,"  etc.,  British  and  Foreign  Medico- Chirurgical  Review,  January, 
1868,  p.  208. 

2  "  The  Physiology  and  Pathology  of  Ilemi-Chorea,"  Edinburgh  Medical  Journal,  Oc- 
tober, 1868. 

3  Op.  cit. 


CHOREA.  719 

In  an  analysis  of  one  hundred  cases  of  chorea,  Dr.  Hughes 1  cites 
fourteen  fatal  cases.  In  all  but  four  of  these  there  was  intra-eranial 
congestion  with  other  structural  changes,  such  as  softening,  opacities, 
and  adhesions.  The  spinal  cord  was  not  examined  in  six  cases.  Of 
the  remaining  eight,  it  was  healthy  in  three,  and  congested,  softened, 
or  with  adhesions  or  opacities  of  the  membranes  in  the  remaining  five. 

In  seven  fatal  cases,  collected  by  Romberg,2  there  was  softening 
and  degeneration  of  different  parts  of  the  brain  and  of  the  spinal  cord. 

Other  similar  cases  have  been  reported,  and  in  the  majority  there 
were  fibrinous  concretions  on  some  portion  of  the  heart's  valves  or 
lining  membrane. 

In  1850  and  18G3,  Dr.  Senhouse  Kirkes3  published  the  details  of  a 
number  of  cases  which  went  to  show  the  association  between  chorea 
and  rheumatism,  and  he  made  the  prediction  that  "future  experience 
will  still  more  positively  demonstrate  that  an  affection  of  the  left  valves 
of  the  heart,  with  the  presence  of  granular  degeneration  upon  them,  is 
an  almost  invariable  attendant  upon  chorea,  under  whatever  circum- 
stances the  chorea  may  be  developed."  The  relation  is  also  insisted 
upon  by  See  and  other  authors,  and  such  cases  as  those  of  Ogle  are 
cited  in  its  support.  But  the  doctrine  is  only  applicable,  with  any 
probability,  to  the  fatal  cases,  and,  in  those  of  Ogle,  rheumatism  was 
not  always  an  antecedent.  In  regard  to  this  point,  I  am  entirely  in 
accord  with  the  views  expressed  by  Dr.  Ogle  in  the  following  extract, 
which  I  make  from  his  valuable  paper  : 

"Again  it  might  be  asked,  if  there  was  merely  a  mechanical  cause 
(which,  of  course,  would  be  constant  in  operation),  such  as  embolism, 
why  should  the  movements  be  so  decidedly  and  universally  interrupted 
during  quiet  sleep  ?  Or,  why  should  certain  peculiarities  as  to  age  or 
be  considered  as  predisposing  influences?  Recognizing  the  fre- 
quent existence  of  these  fibrinous  deposits,  or  granulations,  on  the 
heart's  ralves  in  chorea,  I  should  he  much  inclined  to  look  upon  these 
post-mortem  appearances  rather  as  results  of  some  antecedent  condition 
of  the  blood,  common  also  to  the  choreic  condition,  it  is  very  freely 
recognized  that  this  affection  is  frequently  in  some  way  or  other  con- 
nected with  thai  condition  of  blood  which  obtains  in  what  we  call 
anaemia,  or  that  existing  in  rheumatic  constitutions.     In  both  of  these 

states  wc  know  that  the  Shrine  of  the  blood   is  much  m  excess  (as  also 

it   lb  in  pregnancy  and  other  conditions  looked  upon  as  obnoxious  to 

Chorea),  and    in    these  states  we  know  that    the  fihrine  (with  which  the 

blood  is  surcharged)  is  very  prone  to  be  readily  precipitated,  either 
owing  to  its  superabundance  or  from  other  obscure  ami  acquired  prop- 

1  "  Digest  <>f  one  Hundred  Casee  >.f  Chorea,"  "Quy'a  Hospital  Reports,"  vol.  It.,  1846, 

''  "  Lehrbueb  iter  Nervenkrankheitcn,"  Band  ii. 

8  London  Medical  Ua:etlt,  ls.V>,  ami  Mcdiotl  'I'm.  ■!/.;  1803. 


720  CEREBRO-SPINAL   DISEASES. 

erties  (possibly  also  from  some  interference  with  the  relation  of  the 
fibrin e  and  the  other  constituents  of  the  blood),  upon  the  heart's  walls 
or  valves.  May  not  this  hyperinosis  be  the  explanation  of  the  coinci- 
dence alluded  to  ?  In  most  cases,  the  deposit  is  probably  very  slight, 
and,  in  many  cases,  so  slight  as  to  require  search  for  it.  May  it  not 
infrequently  be  that  it  is  often  only  found  in  quite  the  dying  state  ? 
Speculation  might  suggest  that  the  fibrinous  deposits  arise  from  some 
interference  with  the  degree  of  solubility  of  the  fibrine,  induced  by 
the  presence  of  some  ununited  elements  within  the  blood  (some  result 
of  tissue-metamorphosis)  produced  by  the  excessive  muscular  action 
and  other  functional  disturbance  which  exist  in  the  choreic  state,  thus 
being  not  in  any  way  related  to  this  state  as  a  cause,  but  as  a  conse- 
quence." 

In  the  paper  to  which  reference  has  already  been  made,  Dr.  Hugh- 
lings  Jackson  associates  hemichorea  with  the  plugging  by  emboli  of 
the  vessels  of  the  corpus  striatum  of  one  side,  and,  in  a  recent  valuable 
paper,  Dr.  Charlton  Bastian 1  says  : 

"  I  need  only  hint  at  the  important  bearing  which  the  possibility  of 
the  occurrence  of  minute  embolisms  of  this  kind  may  have  in  the  eluci- 
dation of  previously-obscure  forms  of  so-called  functional  disease  of  the 
nervous  system,  as  I  hope  shortly  to  publish  the  details  of  a  fatal  case 
of  chorea,  in  which  such  embolisms  led  to  ruptures  and  obliterations 
of  small  vessels  throughout  the  corpora  striata  and  in  the  course  of  the 
middle  cerebral  arteries  generally — this  being  a  case  of  bilateral  chorea 
in  which  delirium  was  also  present." 

As  the  result  of  our  present  knowledge  of  the  morbid  anatomy  of 
chorea,  while  it  cannot  be  said  that  we  are  always  able  to  define  its 
seat  with  accuracy,  we  have  strong  evidence  to  support  the  view  that 
it  is  caused  by  either  functional  or  by  organic  irritation  of  motor  cells 
in  the  cerebro-spinal  system.  In  this  respect  it  differs  but  little,  if 
any,  from  the  morbid  anatomy  of  the  other  forms  of  mobile  spasm. 
Irritation  of  the  motor  cells  of  the  cortex,  the  corpus  striatum,  the 
pons,  and  probably  the  spinal  cord,  Is  responsible,  in  my  opinion,  for 
the  manifestations  of  chorea.  As  previously  stated,  I  am  inclined  to 
think  that  there  are  at  least  two  distinct  diseases — one  due  to  spinal 
and  the  other  to  cerebral  lesion,  the  latter  probably  consisting  of  sev- 
eral forms — but  that  it  is  advisable  to  consider  them  as  one  disease  of 
various  types,  until  further  investigation  enables  us  to  speak  with  cer- 
tainty on  the  subject,  and  to  classify  them  according  to  the  morbid 
anatomical  condition  of  each. 

The  investigations  of  Chauveau,2  Le  Gros  and  Onimus,3  and  others, 
upon  choreaic  dogs  :  the  lesions  discovered  in  the  spinal  cord  in  fatal 

1  "  On  the  Plugging  of  Minute  Vessels  in  the  Gray  Matter  of  the  Brain,"  etc.,  British 
Medical  Journal,  January  30,  1S69,  p.  96. 

2  Archiv.  generalcs  de  med.,  18C5.  3  Comptes  rendus,  1870. 


CHOREA.  721 

cases  of  chorea  by  Hughes,1  Romberg,9  Ellischer,8  and  Bastian  ;4  and 
cases  such  as  those  reported  by  Weir  Mitchell  and  Burr,5  show  the 
probability,  at  least,  of  the  spinal  cord  being  the  seat  of  the  primary 
morbid  changes  in  some  instances. 

In  the  paper  already  cited,  Dr.  Hughlings  Jackson  says  of  the  cho- 
reic phenomena  :  "  They  are  not  mere  spasms  and  cramps,  but  an  aim- 
less progression  of  movements  of  considerable  complexity,  much  nearer 
the  purposive  movements  of  health.  They  are  not  so  much  incoher- 
ences of  muscles  (like  the  '  fist '  we  see  in  a  partial  fit  of  those  convul- 
sions, which  begin  unilaterally  where  all  the  muscles  of  the  hand  are 
in  action  at  once)  as  incoherences  of  movements  of  muscles.  There  is 
some  method  in  their  madness.  They  are  not  analogous  to  playing  at 
once  many  keys  of  a  piano  in  mere  order  of  continuity,  but  to  a 
random  playing  of  harmonious  chords.  Again,  they  are  successio?is 
of  movements  ;  moreover,  they  are  successions  of  different  move- 
ments." 

Dr.  Jackson's  theory  of  chorea  is,  that  it  is,  like  epilepsy,  the  result 
of  "  discharging  lesions  "  of  the  cortical  matter  of  the  cerebrum  ;  and 
the  experiments  of  Fritsch  and  Hitzig.  Nothnagel,  Ferrier,  and  others, 
go  very  far  to  confirm  his  views.  Two  essential  points  of  difference 
from  epilepsy  must,  however,  be  noted  :  the  facts  that  in  chorea  there 
is  no  loss  of  consciousness,  and  that  the  discharges  are  successive,  not 
paroxysmal,  and  less  automatic.  Moreover,  his  hypothesis  leaves  out 
of  consideration  the  spinal  element  of  the  disease.  That  there  are  dis- 
charging and  inhibitory  centres  in  the  spinal  cord  is  supported  by  many 
artificial  and  natural  experiments.  The  "spinal  epilepsy"  of  Brown- 
Sequard  is  doubtless  often  a  chorea  of  spinal  origin  ;  and  my  own 
experiments,  cited  under  the  head  of  convulsive  tremor,  also  show  that 
there  are  motorial  centres  in  the  spinal  cord. 

Treatment. — Diseases  which  are  almost  certain  to  terminate  fatally, 
and  those  which  ordinarily  recover  without  medical  treatment,  are 
very  sure  to  have  a  great  many  medicines  used  in  their  therapeutics. 
Chorea  belonging,  as  it  does,  to  this  latter  category,  has  a  medical 
armamentarium  almost  equaling  that  of  hydrophobia.  I  shall,  of 
course,  not  even  pretend  to  mention  all  these  measures,  but  will 
merely  cite  those  which  the  weight  of  evidence,  and  especially  that 
derived  from  my  own  experience,  indicates  as  the  most  effectual.  Of 
the  benefit  to  be  derived  from  proper  medical  treatment  in  shortening 
the.  duration  of  the  disease,  and  preventing  chronicity,  I  have  no  doubt. 

Bromide,  in  some  one  of  its  forms,  is  a  favorite  remedy  for 'chorea. 
I  have  employed  it  in  many  cases,  and  sometimes  with  good  results. 
My  preference  is  for  the  bromide  of  sodium,  in  doses  of  from  (en  t<> 
fifteen  grains,  three  times  a  day,  dissolved  in  a  sufficient  quantity  of 

1  Op.  cit.  ■  Op.  cit.  *  Arehiv  fiir  path.  Anat.,  Berlin,  1871. 

4  Op.  cit.  s  "Traus.  Anicr.  Neurol.  Assoc.,"  1690. 

47 


722  CEREBRO-SriNAL   DISEASES. 

water  to  prevent  gastric  irritation.  In  the  majority  of  instances,  how- 
ever, I  am  opposed  to  its  use.  "While  admitting  that  the  preparations 
of  bromide  diminish  nerve-cell  irritability,  it  is  also  well  established 
that  they  depress  the  system,  weaken  the  muscular  power,  and,  by  con- 
tracting the  arterioles,  prevent  the  proper  nutrition  of  the  brain  and 
spinal  cord.  I  have  therefore  confined  their  administration  to  those 
cases  in  which  the  chorea  coexists  with  maniacal  symptoms,  insomnia, 
or  other  symptoms  of  a  hyperasmic  condition  of  the  brain. 

Iron  is  also  frequently  administered  as  a  sole  remedy,  and  still  more 
generally  as  an  adjuvant.  Indeed,  no  matter  what  special  treatment 
may  be  adopted,  iron  is  generally  indicated  to  improve  the  quality  of 
the  blood.     I  rarely  use  it  unless  for  this  latter  purpose. 

Tartarized  antimony,  copper,  sulphate  of  aniline,  Calabar  bean,  and 
various  other  substances  have  been  employed  with  more  or  less  suc- 
cess, according  to  reports,  but  I  have  little  personal  experience  of  their 
value,  except  as  regards  the  Calabar  bean,  which  I  have  several  times 
employed  as  an  adjuvant,  but  with  doubtful  results. 

I  have  used  both  the  primary  galvanic  and  induced  currents  in 
many  cases.  In  my  opinion  they  are  inefficacious  except  in  that  form 
in  which  there  is  distinct  paralysis. 

Arsenic  enjoys  a  high  reputation  in  the  treatment  of  chorea,  and, 
if  properly  administered,  may  be  regarded  as  almost  a  specific.  It 
should  be  given  in  gradually-increasing  doses  up  to  the  point  of  induc- 
ing evidence  of  its  toxic  influence,  such  as  nausea  and  vomiting  and 
puffiness  of  the  face,  especially  under  the  eyes.  For  a  child  of  five  or 
six  years  the  initial  doses  may  be  four  drops  of  Fowler's  solution  three 
times  a  day  for  the  first  day  ;  for  the  next  day,  five  drops  are  given 
at  a  dose  ;  for  the  next,  six,  and  so  on  till  the  phenomena  mentioned 
appear.  Then  the  doses  should  be  set  back  to  four  or  five  drops,  and 
again  increased  as  before.  Of  the  benefits  of  this  treatment  no  one 
who  has  tried  it  can  have  any  doubt.  Its  advantages  have  been  shown 
in  a  report  of  cases  from  the  clinique  of  the  University  Medical  Col- 
lege, made  by  Dr.  Morton.1  But  the  gastric  method  of  administering 
arsenic  is  not  so  efficacious  in  the  treatment  of  chorea  as  the  hypoder- 
mic, and  in  a  recent  paper2  I  called  attention  to  this  point,  following 
Radcliffe,  who  over  ten  years  ago  introduced  the  practice  : 

In  this  country  hypodermic  injections  of  arsenic  in  the  treatment 
of  chorea  appear  to  have  been  first  used  by  Dr.  J.  Lewis  Smith,3  but 
since  that  time  the  measure  does  not  seem  to  have  attracted  any  at- 
tention. 

For  the  last  ten  years  I  have,  in  obstinate  cases  of  chorea,  em- 

1  "Treatment  of  Chorea  by  Arsenic,"  Neurological  Contributions,  No.  II.,  p.  79. 
s  "  On  the  Treatment  of  Chorea  with  Hypodermic  Injections  of  Arsenic,"  St.  Louis 
Clinical  Record,  October,  18*79. 
3  Medical  Record. 


CHOREA.  723 

ployed  hypodermic  injections  of  Fowler's  solution  with  marked  suc- 
cess. In  recent  or  slight  cases  they  do  not  appear  to  be  necessary, 
these  yielding  readily  to  the  use  of  arsenic  by  the  stomach,  or  very 
often  getting  well  of  themselves  ;  but  in  instances  of  long  standing, 
which  are  generally  classed  as  incurable,  I  am  quite  sure  that  we 
have,  in  the  means  referred  to,  a  valuable  therapeutic  measure,  which 
ought  not  to  be  disregarded. 

In  administering  arsenic  by  thi3  method  a  few  points  of  manipula- 
tion are  to  be  considered,  for  there  is  a  decided  tendency  to  the  causa- 
tion of  cellulitis  and  consequent  abscess,  and  also  of  painful  cutaneous 
inflammation. 

A  point  for  the  injection  should  be  chosen  in  some  part  of  the 
body  where  the  skin  is  loosely  attached  to  the  subjacent  tissues.  The 
skin  near  the  insertion  of  the  deltoid  is  not  a  suitable  place  for  the 
hypodermic  injection  of  arsenic,  however  well  adapted  for  injections 
of  other  substances.  I  very  soon  found  out  that,  when  inserted  there, 
erythema  or  abscess,  or  both,  were  the  invariable  sequences.  More- 
over, the  mere  act  of  injecting  arsenic  in  those  situations  where  the 
skin  is  tight  and  the  tissues  dense  is  accompanied  with  very  consider- 
able pain. 

The  best  point  is  on  the  front  of  the  forearm  about  midway  between 
the  wrist  and  the  bend  of  the  elbow.  Here  the  skin  is  loose,  and  can 
be  easily  lifted  up  by  the  thumb  and  finger  from  the  tissues  below. 
In  the  next  place  the  arsenic  should  be  deposited  just  under  the  skin 
in  the  cellular  tissues,  and  not  in  the  substance  of  the  skin  or  muscles. 
Neglect  of  this  point  will  almost  invariably  lead  to  the  formation  of 
abscess.  The  point  of  the  syringe  should  therefore  be  just  carried 
through  the  skin  and  then  for  about  half  an  inch  parallel  to  the  face 
of  the  arm.  The  injection  should  then  be  made  slowly,  and  it  is  well 
to  lift  up  the  skin  over  the  place  where  the  injection  has  been  made, 
so  as  further  to  facilitate  its  absorption. 

And,  lastly,  it  will  not  do  to  inject  the  undiluted  Fowler's  solution, 
for  if  this  provision  be  not  followed,  cellulitis,  erythema,  and  intense 
pain,  will  certainly  be  produced.  The  dose  which  it  is  deemed  proper 
to  inject  should  be  diluted  with  at  least  an  equal  quantity  of  water, 
or,  preferably,  of  glycerine.  The  latter  substance  seems  to  be  more 
readily  absorbed  and  to  produce  less  irritation  than  water.  All  these 
precautions  are  for  the  purpose  of  preventing  local  troubles.  There  is 
certainly  a  strong  disposition  on  the  part  of  arsenic  to  produce  them. 
If,  however,  attention  be  paid  to  the  rules  I  have  laid  down,  there 
will  rarely,  if  ever,  be  any  local  disturbance. 

The  dose  of  arsenic  administered  by  hypodermic  injection  may  be 
very  considerably  larger  than  that  which  the  stomach  will  ordinarily 
tolerate,  and  it  is  just  here  that  the  superior  advantages  of  the  method 

are  most    clearly  shown.      It  is  in  chronic   cases  of  chorea   and   certain 


724  CEREBRO-SPINAL   DISEASES. 

choreiform  affections  that  large  doses  of  arsenic  are  especially  re- 
quired, and  the  effect  of  such  doses  in  curing  the  disease  is  not  only 
generally  prompt^  but  is  unassociated  with  any  toxic  phenomena.  I 
have  frequently  given  as  high  as  thirty-five  drops  of  Fowler's  solution 
by  hypodermic  injection  as  an  initial  dose.  It  is  very  certain  that  the 
stomach  would  not  tolerate  this  quantity.  Again,  I  have  often  car- 
ried the  amount  taken  by  the  stomach  to  the  utmost  bounds  of  pru- 
dence— till  the  eyes  were  puffed,  and  vomiting  was  almost  incessant — 
and  then  have  continued  the  arsenic  in  larger  doses  by  hypodermic 
injection,  with  the  result  of  the  cessation  of  all  gastric  symptoms  and 
the  rapid  cure  of  the  disorder. 

With  these  introductory  remarks  I  pass  to  the  description  of  two 
or  three  cases  in  which  the  beneficial  effects  of  the  arsenic  adminis- 
tered hypodermically  were  unquestionable  : 

Case  I. — Mrs.  A.  C,  of  Jersey  City,  consulted  me,  not  for  chorea, 
but  for  a  spasmodic  affection  of  the  muscles  of  the  neck  attended 
with  great  pain.  On  examination,  I  found  that  the  left  sterno-cleido- 
mastoid  was  the  subject  of  clonic  spasm,  and  that  the  left  trapezius 
was  also  similarly  involved.  As  a  consequence  the  head  was,  every 
few  seconds,  jerked  round  toward  the  right  shoulder,  at  the  same  time 
being  drawn  backward.  It  was  possible,  by  a  strong  effort  of  the 
will,  to  arrest  these  movements  for  a  half  a  minute,  and  at  times,  when 
alone  and  undisturbed,  they  were  less  strong  and  frequent.  During 
sleep  they  entirely  ceased.  The  affection  had  come  on  suddenly  some 
five  years  previously,  apparently  as  the  result  of  exposure  to  cold. 
No  therapeutic  measures  (among  which  had  been  electricity,  water- 
cure,  and  braces  of  various  kinds)  had  produced  the  slightest  bene- 
ficial effect. 

In  the  beginning  I  administered  Fowler's  solution  in  doses  of  eight 
drops  three  times  a  day,  increasing  the  doses  a  drop  every  day.  When 
sixteen  drops  were  reached,  the  skin  around  the  eyes  became  puffed, 
and  each  dose  excited  nausea  and  vomiting.  Up  to  this  time  there 
bad  been  a  very  slight  degree  of  improvement,  but  I  found  it  was  im- 
possible to  carry  the  arsenic  far  enough  when  administered  by  the 
stomach  to  get  the  full  effect  of  the  drug.  I  therefore,  on  the  20th, 
administered  hypodermically  one  injection  of  twenty-five  drops  diluted 
with  a  like  quantity  of  glycerine.  On  the  21st  she  received  thirty 
drops,  and  now  there  were  decided  evidences  of  improvement — the 
pain  was  greatly  mitigated,  and  the  spasmodic  movements  were  less 
extensive  and  less  frequent.  On  the  21st  thirty-two  drops  were  given, 
and  on  the  22d  thirty-five.  The  amelioration  was  now  still  more 
strongly  marked,  and  by  continuing  the  doses  of  thirty-five  drops  till 
the  25th  the  pain  and  the  movements  were  caused  to  cease  entirely. 
The  medicine  was  now  stopped,  and  the  patient  has  remained  to  this 
day  free  from  any  spasm.     There  is  still  (October  6th)  a  slight  ten- 


CHOREA.  725 

dency  for  the  head  to  turn  to  the  right,  hut  this  is  being  gradually 
overcome,  and  the  power  over  the  formerly  affected  muscles  is  com- 
plete. 

Case  II. — Miss  H.,  aged  twelve,  a  young  lady  from  Texas,  was 
brought  to  me  by  ber  mother  to  be  treated  for  chorea,  with  which  she 
had  been  affected  for  several  months.  The  muscles  chiefly  affected 
were  those  of  the  face,  both  shoulders,  and  both  upper  extremities,  but 
at  times  there  was  a  curious  protrusion  of  the  abdomen  from  the  spas- 
modic action  of  the  erector  spina?  muscle. 

I  at  once  began  the  treatment  with  arsenic  and  the  application  of 
pulverized  ether  to  the  spine,  the  former  in  doses  of  five  drops  of 
Fowler's  solution  three  times  a  day,  increased  a  drop  every  alternate 
day,  and  the  latter  once  daily.  By  the  time  ten  drops  of  the  arsenical 
solution  was  reached  (which  was  in  ten  days),  there  was  decided  im- 
provement. The  eyes  were  slightly  puffed,  but  the  stomach  bore  the 
remedy  exceedingly  well.  I  continued  the  medicine  up  to  fourteen 
drops  without  exciting  gastric  disturbance,  and  then,  as  the  choreic 
movements  had  ceased,  I  refrained  from  further  increase,  but  kept  on 
with  the  doses  of  fourteen  drops  for  three  or  four  days  longer.  She 
then  went  home  cured. 

But  in  six  months  she  returned  to  me,  with  all  the  choreic  symp- 
toms as  bad  as  ever,  and  her  mother  informed  me  they  had  made  their 
appearance  a  couple  of  weeks  before  without  apparent  cause.  I  again 
tried  the  arsenical  treatment  with  ether  to  the  spine,  which  had  been 
so  beneficial  the  year  before,  but  it  was  now  apparent  that,  from  some 
cause  or  other,  the  stomach  had  become  intolerant  of  the  drug,  for  I 
found  it  impossible  to  administer  with  safety  more  than  eight  drops, 
and  this  quantity  had  no  beneficial  influence  over  the  disease.  I  there- 
fore determined  to  use  the  hypodermic  injections.  Twelve  drops  were 
the  initial  dose,  the  next  day  thirteen  were  given,  the  next  fourteen, 
and  the  next  fifteen.  There  were  no  choreic  movements  after  this  dose 
was  attained.  It  was  given  daily  for  a  week,  and  then  the  patient  was 
discharged  cured.  In  all  this  time  there  had  been  no  toxic  symptoms 
beyond  slight  puffing  of  the  face. 

Cask  III. — I.  II.,  a  boy  eight  years  of  age,  was  brought  to  me 
affected  with  general  chorea.  The  case  was  a  chronic  one,  having 
lasted  alx.ut  a  year,  and  had  been  treated  by  his  physician  with  a 
single  drop  of  Fowler's  solution  administered  once  every  alternate 
day,  ami  with  sulphate  of  zinc  in  about  as  efficacious  doses.  I  be- 
gan the  treatmenl  in  this  case  with  hypodermic  injections  of  five 
drops  of  Fowler's  solution  given  daily,  and  every  alternate  day  in- 
creased   a   drop.      In    ten    days   thereafter   the    patient  was  taking  ten 

drops  daily,  A-  by  thi^  time  greal  amelioration  had  ensued,  I  did  not 
carry  the  increase  farther,  but,  with  the  view  of  preventing  a  relapse, 
the  doses  ueic  continued   for  several  da_\>.     On  the  28th  all  treat- 


726  CEEEBRO-SriNAL   DISEASES. 

ment  was  suspended,  the  patient  being  entirely  free  from  choreiform 
movements. 

In  cases  of  acute  chorea,  a  large  number  of  which  I  have  treated 
with  hypodermic  injections  of  arsenic,  smaller  doses  may  be  given  than 
when  administered  by  the  stomach,  and  they  do  not  require  to  be  so 
frequently  repeated.  Thus  it  often  suffices,  for  the  speedy  cure  of  the 
disease,  to  give  four  drops  of  Fowler's  solution  hypodermic-ally  every 
alternate  day  for  a  week  or  ten  days,  and  then  to  increase  the  dose  to 
five  drops  for  a  like  period.  I  have  compared  the  duration  of  acute 
chorea  as  treated  by  the  gastric  and  hypodermic  administration  of 
arsenic,  and  have  ascertained  that  the  period  is  shortened  one  half  by 
the  latter  method.  While  admitting  that  the  tendency  in  such  cases 
is,  with  hygienic  measures,  toward  a  cure,  the  beneficial  effects  of  the 
arsenic  are  none  the  less  evident.  I  have  repeatedly  seen  the  most 
marked  improvement  result  from  a  single  injection. 

In  his  excellent  monograph  Garin '  has  insisted  on  the  advantages 
of  this  method  of  treating  chorea,  and  has  adduced  many  instances  of 
its  good  effects. 

As  to  the  employment  of  strychnia,  as  detailed  in  former  editions 
of  this  work,  I  am  not  disposed  to  recommend  it,  in  view  of  the  excel- 
lent results  obtainable  by  the  use  of  arsenic,  except  in  special  cases,  in 
which,  from  some  idiosyncrasy,  the  latter  medium  is  not  tolerated. 
It  may  also  be  of  service  as  an  adjunct  in  moderate  doses. 

The  ether-spray  to  the  spine,  as  employed  by  Lubilski,  Zimberlin, 
and  others,  is  also  an  excellent  adjuvant.  Its  effect  is  immediately 
quieting,  and  it  may  be  used  two  or  three  times  a  day  for  five  or  six 
minutes  along  the  whole  length  of  the  spine. 

In  the  paroxysmal  forms  of  chorea,  ether  or  chloroform  by  inhala- 
tion is  often  necessary  to  cut  short  or  prevent  an  immediate  seizure, 
but  in  other  respects  the  treatment  mentioned  is  entirely  applicable. 

In  all  cases  hygienic  measures  are  of  the  utmost  importance.  Ex- 
ercise in  the  open  air  is  indispensable  ;  the  food  should  be  of  the  most 
nutritious  character  ;  the  bedroom  should  be  well  ventilated  ;  bathing 
should  be  frequent  ;  the  bowels  should  be  kept  well  regulated  ;  and 
the  child,  if  at  school,  should  be  at  once  removed,  and  all  study  for 
the  time  be  interdicted.  Ridicule  or  threats,  so  often  indulged  in 
toward  choreic  children,  generally  do  harm,  but  at  the  same  time 
they  should  be  encouraged  to  use  all  reasonable  effort  to  prevent  a 
bad  habit  being  formed.  In  the  epidemic  variety  of  the  disorder, 
threats,  and  even  strong  repressive  measures,  are,  on  the  contrary, 
decidedly  beneficial  in  curing  and  arresting  the  further  progress  of  the 
disease. 

It  is  certainly  advantageous  to  keep  the  patient  mentally  and  phys- 

1  "  Du  traitcment  dc  la  choree  sp6cialmcnt  par  1'arsenic  ct  les  injections  du  liqueur  de 
Fowler,"  Paris,  1879. 


HYSTERIA.  727 

ically  in  a  state  of  comparative  repose,  but  I  have  never  obtained  any 
beneficial  effect  from  confining  him  to  bed  in  a  dark  room,  as  recom- 
mended by  some  writers.  On  the  contrary,  I  have  several  times  seen 
the  disorder  aggravated  by  this  measure.  It  is  one  that  is  particularly 
distasteful  to  most  children,  and  hence  keeps  them  in  a  continual  state 
of  fretfulness  and  excitement.  Moreover,  it  is  a  measure  decidedly 
antagonistic  to  the  general  good  health  of  the  patient,  who  requires 
light  and  fresh  air  as  influential  hygienic  factors  in  bringing  about  a 
favorable  result.  As  regards  mental  occupation,  hard  study  is  of 
course  to  be  avoided  ;  but  I  do  not  think  it  advisable  to  prohibit  the 
reading  of  such  books  as  amuse,  without  requiring  any  considerable 
degree  of  intellectual  effort  for  their  understanding. 


CHAPTER  V. 

HYSTERIA. 

A  large  volume  might  be  written  on  hysteria — and  many  such 
have  been  published — and  there  would  still  be  points  in  its  clinical  his- 
tory unconsidered.  It  is  difficult,  therefore,  in  a  general  treatise  like 
the  present,  to  give  a  full  view  of  a  disease  which  plays  so  important  a 
part  in  nervous  pathology,  and  which  is  so  varied  in  its  manifestations. 
The  most  that  I  can  hope  to  do  is  to  lay  down  certain  broad  principles 
and  features,  and  leave  the  recognition  of  details  to  the  intelligence  and 
discrimination  of  those  who  read  this  work. 

Symptoms. — The  phenomena  of  hysteria  may  be  manifested,  as  re- 
gards the  mind,  sensibility,  motility,  and  visceral  action,  separately  or 
in  any  possible  combination.  Thus  it  is  not  uncommon  to  meet  with 
cases  in  which  the  only  evidence  of  the  disease  is  seen  in  abnormal 
mental  action  ;  others  are  characterized  solely  by  derangements  of  sen- 
sibility, such  as  hyperesthesia  or  anaesthesia  ;  others  by  aberration  of 
the  faculty  of  motion,  such  as  paralysis,  spasms,  contractions.  Again, 
all  of  these  categories  may  be  witnessed  in  the  same  person,  giving 
among  other  phenomena,  to  coma  and  convulsions  ;  and  again, 
some  one  or  more  of  the  viscera  may  be  deranged  in  their  functions, 
and  thus  the  appearance  of  organic  disease  be  simulated. 

As  there  is  such  a  marked  want  of  uniformity  in  the  character  cf 
hysteria  as  it  affects  different  persons,  I  will  not  endeavor  to  present  a 
typical  case  of  the  disorder,  but  will  consider  separately  the  principal 
phenomena  which  may  have  an  hysterical  origin.  But,  in  setting  out 
to  make  the  attempt,  I  am  reminded  of  Dante's  despair  at  the  thought 
of  his  inability  to  describe  the  horrors  of  the  ninth  gulf  : 


728  CEREBRO-SPINAL   DISEASES. 

"  Chi  poria  mai  pur  con  parole  sciolte 
Dicer  del  sangue,  e  delle  piaghe  appieno, 
Ch'io  ora  vidi,  per  narrar  piu  volte? 

Ogni  lingua  per  certo  verria  meno, 
Per  lo  nostro  sermone,  e  per  la  mcute, 
O'hanno  a  tanto  comprender  poco  seno." 

The  Hysterical  Diathesis. — Though  it  is  very  common  to  hear  the 
hysterical  diathesis  or  temperament  mentioned  by  medical  authors,  I 
have  never  been  able  to  recognize  its  existence  by  any  external  traits. 
The  fact  that  it  has  been  so  very  differently  described  by  writers,  from 
Hippocrates  and  Galen  to  our  own  day,  is  good  evidence  that  it  is  not 
readily  detected. 

Thus,  Hippocrates  and  Galen  recognized  the  existence  of  the  hys- 
terical temperament,  but  each  gave  it  different  characteristics.  Lou- 
yer-Villermy '  had  very  decided  views  of  its  features,  and  he  described 
it  as  follows  : 

"  Every  hysterical  woman  is  stout,  short,  dark,  plethoric,  full  of  life 
and  of  health.  The  complexion  is  brunette  and  ruddy,  the  eyes  black 
and  sparkling,  the  mouth  large,  the  teeth  white,  the  lips  of  a  carnation 
red,  the  hair  luxuriant  and  of  the  color  of  jet,  the  sexual  organs  well 
developed,  and  the  spermatic  liquid  abundant." 

Aside  from  his  physiological  error  relative  to  the  spermatic  liquid, 
these  are  the  characteristics  of  the  women  of  the  south  of  Europe.  If 
he  had  lived  in  the  north,  where  hysteria  is  fully  as  common,  he  would 
have  found  that  his  description  of  the  hysterical  temperament  would 
not  have  held  good.  Indeed,  Sydenham,  Whyte,  Copland,  and  other 
English  authors,  represent  the  hysterical  predisposition  with  almost  the 
very  opposite  characteristics.  As  Briquet2  remarks,  there  is  no  hyster- 
ical constitution  appreciable  by  the  study  of  external  appearances. 
The  disease  takes  women  as  it  finds  them,  blondes,  brunettes,  stout, 
thin,  strong,  weak,  ruddy,  or  pale,  there  is  no  choice.  Some  hysterical 
women  have  delicate  figures  and  intelligent  minds,  but  there  are  others 
whose  dull,  stolid  faces  give  evidence  of  their  stupidity  ;  and  others, 
again,  whose  thin,  fleshless,  and  wan  faces  tell  us  that  the  Greek  type 
of  female  beauty  is  not  to  be  regarded  as  predisposing  to  the  develop- 
ment of  hysteria. 

While,  therefore,  admitting  the  existence  of  the  hysterical  diathesis, 
I  know  of  no  marks  by  which  its  presence  can  be  determined,  other 
than  the  acts  of  the  patient,  which  go  to  make  up  the  clinical  history. 

Mental  Symptoms. — These  are  very  various,  but  generally  consist 
in  emotional  disturbance,  an  inability  or  indisposition  to  exert  the  will, 
and  in  the  existence  of  illusions,  hallucinations,  or  delusions.     Attacks 

1  Quoted  by  Briquet,  "  Traite  clinique  et  therapeutique  de  l'hysterie,"  Paris,  1859, 
p.  91. 

8  Op.  til.,  p  92. 


HYSTERIA.  729 

are  often  characterized  by  no  other  prominent  symptoms  than  those 
connected  with  mental  action,  and  they  may  assume  every  possible 
character.  At  times,  the  patient  is  depressed  in  spirits,  and  sheds  tears 
profusely  ;  a  few  minutes  afterward,  she  has  forgotten  her  grief,  and 
laughs  immoderately,  without  adequate  cause.  Sometimes  she  laughs 
and  cries  at  the  same  time. 

Or,  there  may  be  a  total  insusceptibility  to  any  emotion,  a  listless 
insouciance,  which  contrasts  strongly  with  her  natural  disposition.  Or, 
again,  an  emotion  the  exact  opposite  of  the  proper  one  is  excited.  This 
is  quite  a  common  form  of  manifestation.  A  mother,  for  instance,  is 
informed  that  her  daughter  has  contracted  an  improper  marriage,  and 
is  immediately  seized  with  immoderate  laughter,  and  shows  every  ex- 
pression of  pleasure,  when  the  rest  of  the  family  are  overwhelmed  with 
grief  and  shame.  Another  draws  the  chief  prize  in  a  lottery,  and  be- 
gins at  once  to  cry  and  wring  her  hands.  A  third,  hearing  that  bur- 
glars have  entered  the  house  and  have  stolen  all  her  jewelry  and  silver, 
sits  stolidly  in  her  chair,  her  hands  folded  in  her  lap,  and  her  whole  ex- 
pression indicating  the  most  complete  indifference.  During  either  of 
these  conditions,  she  may  be  entirely  silent,  or  excessively  voluble,  or 
she  may  exhibit  other  hysterical  phenomena. 

As  regards  the  will,  the  manifestations  of  disorder  are  sometimes 
very  remarkable.  That  the  patient  is,  for  the  time  being,  unable  to 
exert  it,  is  evident,  but,  under  the  influence  of  some  strong  exciting 
cause,  she  frequently  astonishes  those  about  her  by  suddenly  reacquir- 
ing her  lost  volitional  power. 

A  young  lady  came  under  my  charge  for  what  was  supposed  to  be 
a  disease  of  the  spinal  cord.  She  had  taken  to  her  bed  suddenly,  soon 
after  striking  her  back  rather  gently  against  the  edge  of  a  table,  declar- 
ing that  she  could  not  walk.  On  examination,  I  was  convinced  that 
there  was  no  disease  whatever  of  the  spine,  other  than  that  of  a  purely 
hysterical  character,  and  I  so  expressed  myself  to  her.  She,  neverthe- 
less, insisted  upon  it  that  her  spine  was  seriously  injured,  and  she  con- 
tinued to  keep  her  bed,  lamenting  daily  her  sad  fate  at  being  compelled 
to  pass  so  long  a  time  shut  out  from  the  enjoyments  of  life.  There  was 
no  paralysis  or  even  simulation  of  it,  for  she  moved  her  legs  about 
freely  enough  in  the  bed.  But,  one  evening,  her  brother,  who  had  long 
been  absent,  returned  home.  She  heard  the  bustle  in  the  house  attend- 
ant upon  his  arrival,  but  all  were  too  busy  to  pay  any  attention  to  her 
in  her  chamber  up-stairs.  Suddenly  exclaiming,  "I  can  stand  this  no 
long)  r,"  she  sprung  from  her  bed,  rang  for  her  maid,  and,  hurrying  on 
her  clothes,  proceeded  down-stairs  and  entered  the  drawing-room,  to 
lip-  greal  Burprise  <>f  all  the  family. 

In  another  case,  a  lady  closed  her  eyes,  and  deolared  (ha*  slm  could 
not  open  thorn.  She  was  brought  to  me  as  a  case  of. double  ptosis. 
There  was  no  spasm  of  the  orbicularis  palpebrarum  on  either  side,  and 


730  CEREBRO-SPIXAL   DISEASES. 

I  had  no  difficulty  in  opening  the  eyes  by  gently  raising  the  lids.  The 
pupils  were  normal;  there  was  no  diplopia,  and  there  were  no  evidences 
of  such  cerebral  lesions  as  are  generally  met  with  as  causes  of  ptosis. 
Moreover,  she  was  subject  to  paroxysms  of  hysterical  svncope.  Under 
the  circumstances,  I  had  no  hesitation  in  expressing  my  opinion  to  her 
friends  that  the  case  was  one  of  hysteria.  I  advised  the  use  of  the  in- 
duced current  to  the  eyes,  and  she  found  this  so  disagreeable,  not  to  say 
painful,  that  two  applications  were  sufficient  to  restore  her  volitional 
power,  so  that  she  opened  her  eyes  without  difficulty. 

In  my  remarks  on  aphasia,  I  have  cited  a  case  (p.  182)  in  which  the 
power  to  speak  suddenly  returned  under  the  influence  of  excitement, 
and  was  suddenly  lost  again,  to  be  gradually  recovered. 

Many  cases  of  this  loss  of  volition  in  hysteria  have  been  under  my 
care,  and  most  physicians  have  witnessed  similar  instances. 

Illusions  are  very  common  phenomena  of  hysteria,  and  these  may  be 
connected  with  any  or  all  of  the  senses.  A  ball  rolling  over  the  floor 
is  taken  for  a  rat;  the  sound  of  rain  falling  on  the  roof  is  mistaken  for 
the  noise  of  burglars  in  the  next  room;  the  knives  used  at  table  all 
"  smell  fishy; "  every  thing  tastes  sour  or  bitter  or  sweet,  as  the  case  may 
be,  and  a  draught  of  cold  air  on  the  hand  is  supposed  to  be  the  touch  of 
a  person  or  a  spirit. 

Hallucinations  of  various  kinds  are  equally  frequent.  Images  are 
seen  where  there  is  nothing;  voices  are  heard  where  there  is  absolute 
silence;  odors  are  smelt  where  there  is  nothing  to  smell;  and  strange 
tastes  are  perceived  when  the  mouth  is  empty. 

Thus  one  patient  sees  angels,  another  demons,  another  animals  of 
various  kinds.  .  One  hears  voices  whispering  to  her,  another  musical 
sounds,  and  another  noises  like  the  breaking  of  glass  or  dishes.  Another 
is  constantly  sensible  of  a  smell  as  if  something  is  burning,  and  another 
always  has  a  taste  of  turpentine  in  her  mouth. 

It  is  not  often  the  case  that  these  erroneous  perceptions  impose  on 
the  intellect,  but  sometimes  they  do,  and  then  delusions  are  enter- 
tained, or  these  may,  as  in  cases  of  absolute  insanity,  be  formed  with- 
out the  intervention  of  the  deranged  perceptive  faculties.  They  differ 
however,  from  the  delusions  of  insanity,  such  as  have  been  already 
described,  in  the  facts  that  they  do  not  last  long  and  that  they  rarely 
exercise  any  powerful  influence  over  the  actions  of  the  patients. 

Besides  these  mental  phenomena  indicative  of  cerebral  disturbance, 
there  are,  sometimes,  an  extraordinary  acuteness  of  understanding  and 
readiness  at  reasoning  and  speech  quite  beyond  the  natural  powers  of 
the  patient.  At  other  times,  on  the  contrary,  the  intellect  is  dulled, 
and  the  conversational  power  reduced  to  a  low  point. 

Sensibility. — This  may  be  affected  so  as  to  result  in  the  production 
either  of  hyperesthesia  or  anaesthesia. 

Hyperesthesia,  caused  by  hysteria,  is  characterized  by  the  facts  that 


HYSTERIA.  731 

it  is  never  permanently  fixed  in  one  place,  that  it  is  generally  exces- 
sively acute,  and  that  it  is  unaccompanied  by  evidences  of  serious  dis- 
ease of  the  nervous  centres  or  the  nerves.  A  common  seat  is  the  skin, 
and  its  favorite  region  is  the  trunk,  especially  the  skin  over  the  mam- 
mary glands,  and  that  covering  the  labia  majora.  Another  situation 
frequently  affected  is  the  skin  of  the  face. 

Cutaneous  hyperesthesia  may  consist  either  of  spontaneous  pain  or 
of  tenderness  to  impressions  made  upon  the  surface  of  the  body.  Mus- 
cular hyperesthesia,  or  myalgia,  is  likewise  common.  Dr.  Inman l  has 
investigated  this  branch  of  the  subject  very  carefully,  and  has  ascer- 
tained that  the  painful  spots  correspond  to  the  origins  and  insertions 
of  the  muscles. 

Muscular  pains  due  to  hysteria  are  often  mistaken  for  pains  of  the 
viscera.  Thus  the  headache  which  is  so  frequent  a  phenomenon  of  the 
hysterical  condition  is  very  seldom  located  within  the  cranium.  It  may 
be  of  very  limited  extent,  constituting  the  form  known  as  the  clavus 
hystericus,  or  may  be  of  more  extensive  limits.  Its  ordinary  situations 
are  the  frontal  regions,  occupying,  in  this  case,  the  occipito-frontalis 
and  corrugator  supercilii  muscles  ;  the  temporal  regions,  being  then 
located  in  the  temporal  muscles;  the  vertex,  being  then  seated  in  the 
tendon  of  the  occipito-frontalis  muscle;  and  the  occipital  region,  in  the 
occipito-frontalis,  trapezius,  splenius,  and  complexus.  Briquet  states 
that,  of  three  hundred  and  fifty-six  hysterical  patients  whom  he  ques- 
tioned on  the  subject,  three  hundred  were  constantly  subject  to  head- 
ache. I  have  very  rarely  met  with  a  case  of  hysteria  in  which  it  was 
not  almost  constantly  present,  and  never  one  in  which  it  was  not  a 
symptom  at  some  time  or  other. 

Pains  are  often  felt  in  the  muscles  of  the  chest,  abdomen,  and  back. 
This  latter  is  a  favorite  situation,  especially  in  the  region  between  the 
shoulders,  and  in  the  muscles  on  each  side  of  the  vertebral  column  in 
the  lumbar  region. 

Pains  in  the  joints  are  common  manifestations  of  hysteria,  and  they 
are  often  mistaken  for  serious  organic  disease.  When,  as  is  sometimes 
the  case,  they  are  accompanied  with  contractions  of  the  muscles,  the 
liability  to  error  on  the  part  of  the  practitioner  is  increased.  Sir  Ben- 
jamin Brodie,'  several  years  ago,  pointed  oui  the  true  nature  of  certain 
affections  of  tin-  joints  occurring  in  hysterical  women  ;  and,  since  his 
time,  others,  among  whom  Barlow1  and  Skey*  are  to  be  mentioned, 
have  called  special  att<  ntion  to  the  subject.  The  pain  may  lie  attended 
with  swelling,  but  there  is  no  accumulation  of  fluid  in  the  cavity  of  the 

1  "On  Myalgia:  it-  Nature,  Causes,  and  Treatment,  etc.,"  London,  1860. 
■  "Illustrations  of  Certain  Local  Nervous  affections,"  London,  18 
8  "A  Treat  of  the  Joints,"  London. 

'"Hysteria,  etc.    Si\  Lectures  delivered  ti>  the  Students  of  St.  Bartholomew's  Ilof- 
pital,  L868,"  London,  1867. 


732  CEREBRO-SPIXAL   DISEASES. 

synovial  membrane.  The  knee  is  more  frequently  affected  than  any 
other  joint. 

Quite  recently  a  young  lady  has  been  under  my  charge  whose  knee 
had  been  for  two  years  kept  in  a  steel  apparatus  for  the  purpose  of 
preventing  motion.  Careful  examination  convinced  me  that  this  was  a 
case  of  hysterical  joint.  I  therefore  flexed  and  extended  the  limb 
several  times  to  its  utmost  limits,  told  her  to  throw  away  the  steel 
rods,  and  to  walk  on  the  leg  as  much  as  she  pleased.  Within  six  months 
she  walked  as  well  as  she  ever  had,  and  was  even  able  to  waltz  with 
ease,  with  no  other  treatment  than  daily  passive  movements  of  the 
joint. 

In  regard  to  these  neuroses  Meyer  *  has  lately  communicated  much 
interesting  information,  and  has  indicated  the  leading  phenomena  which 
suffice  to  distinguish  them  from  organic  diseases.  Thus  the  pain  ceases 
at  night,  light  handling  is  more  painful  than  severe  pressure,  transient 
swellings  are  apt  to  occur,  the  temperature  of  the  part  is  subject  to 
changes,  there  is  no  tendency  to  atrophy  of  the  muscles  in  the  vicinity, 
and  they  are  often  cured  spontaneously,  or  by  prayer,  or  by  sudden 
movements  of  the  joint,  or  by  some  powerful  physical  cause. 

Neuralgia  often  has  a  hysterical  origin,  and  may  be  in  the  form  of 
toothache,  pleurodynia,  sciatica,  or  pain  in  the  course  of  any  other  nerve. 
The  viscera  are  likewise  frequently  hyperaesthetic;  the  stomach,  bowels, 
the  kidneys,  bladder,  uterus,  and  ovaries,  are  the  organs  most  frequently 
affected.  And  of  these  the  most  common  seat  of  hyperesthesia  in  hys- 
terical women  is  the  ovary,  and,  according  to  Chairou,2the  left  ovary  more 
frequently  than  the  right.  I  have  several  times  succeeded  in  causing 
hysterical  attacks  by  moderate  pressure  on  the  ovary,  and  have  rarely 
failed  to  find  one  or  both  the  seat  of  marked  tenderness  in  cases  of  the 
affection.  Indeed,  so  common  is  it  to  find  ovarian  tenderness  in  hys- 
terical women,  that  I  am  almost  disposed  with  Chairou  to  regard  this 
condition  as  a  pathognomonic  sign.  Charcot  3  also  lays  great  stress 
on  the  symptom. 

The  organs  of  the  special  senses  rarely  escape  having  their  sensi- 
bility exalted,  and,  consequently,  there  are  increased  power  of  vision, 
morbid  acuteness  of  hearing,  and  an  abnormal  sensitiveness  of  the 
smell  and  taste.  Sometimes  with  these  hyperesthetic  conditions  there 
is  pain. 

Anaesthesia. — Though  not  so  common  as  hyperesthesia,  anaesthesia 
is  frequently  a  manifestation  of  hysteria.  One  of  its  most  common  seats 
is  the  skin.  In  the  days  of  witchcraft,  many  a  hysterical  woman  with 
anaesthetic  spots  on  her  skin,  went  to  the  gallows  or  the  stake  on  sus- 

1  Berliner  kliiiiache  WocJienschri/t,  No.  26,  1874.  Also  Psychological  and  Medico- 
Legal  Journal,  September,  1874. 

8  "Etude?  cliniques  sur  la  hjsterie,"  Paris,  1870,  p.  7. 
3  Op.  cit .  p.  283. 


HYSTERIA.  733 

picion  of  being  leagued  with  the  devil.  The  belief  was  that,  wherever 
the  hand  of  the  arch-fiend  or  his  assistants  touched  the  skin,  the  spot 
at  once  lost  its  sensibility. 

Two  patients  are  now  under  my  charge  in  whom  there  is  hemi-anaes- 
thesia,  paroxysmal  in  its  character.  When  it  is  at  its  height,  no  irri- 
tation applied  to  the  skin  is  felt,  not  even  the  wire  brush  of  a  powerful 
induction-coil.  In  neither  case  are  the  attacks  preceded  or  accompanied 
by  numbness. 

Sometimes  the  location  is  very  limited,  and  the  loss  of  sensibility 
may  be  partial  or  complete.  In  the  former  case  there  is  numbness, 
and  the  full  extent  can  only  be  exactly  ascertained  by  the  aesthesi- 
oineter. 

The  mucous  membranes  may  become  anaesthetic.  One  frequently 
affected  is  that  which  lines  the  genital  canal.  In  such  a  case,  the  sexual 
passion  is  entirely  extinguished,  coition  is  unattended  with  pleasure, 
and  may  even  excite  disgust. 

The  organs  of  the  special  senses  may  be  the  seat  of  anaesthesia,  and 
thus  blindness,  deafness,  loss  of  the  senses  of  smell  and  of  taste,  may 
be  caused,  more  or  less  complete  in  character,  in  different  cases. 

Chairou  '  has,  however,  shown  that  in  all  cases  of  hysteria  the  reflex 
excitability  of  the  larynx  is  abolished.  If  in  a  hysterical  woman  the 
finger  be  passed  down  the  throat  so  as  to  be  brought  in  contact  with 
the  epiglottis,  it  will  be  found  that  this  part  is  absolutely  insensible, 
and  that  it  can  be  rubbed  or  even  scraped  with  the  nail  without  caus- 
ing irritation  of  any  kind.  Or  the  superior  orifice  of  the  larynx  may  be 
similarly  treated  with  the  finger  or  with  a  probang,  a  feather,  a  roll  of 
paper,  or  any  similar  instrument,  without  exciting  either  cough  or  efforts 
to  vomit. 

Since  becoming  acquainted  with  Chairou's  observations  I  have  inva- 
riably made  such  an  operation  as  that  described  a  part  of  my  examina- 
tion of  hysterical  persons  male  or  female,  and  have  never  failed  to 
verify  his  statements.  It  is  somewhat  astonishing  that  his  observations 
have  attracted  so  little  attention. 

Anaesthesia  of  the  muscles  is  occasionally  met  with,  and  has,  at 
times,  been  the  occasion  of  much  discussion  in  medical  and  theological 
circles.  Many  of  the  phenomena  observed  in  the  Jansenist  convuhion- 
naires  were  the  result  of  muscular  anaesthesia.  In  an  essay3  recently 
published,  I  have  called  attention  to  the  Bymptoms,  and  hare  adduced 
several  cases  from  the  records  of  my  own  experience.  The  extent  of 
the  anaesthesia  is  sometimes  remarkable.  In  some  of  the  oases  thai 
have  been  under  my  care,  the  most  powerful  induced  currents  which  it 
was  safe  to  use,  failed  to  cause  pain  in  the  muscles  to  which  they  were 
applied. 

1  Op.  eft.,  p.  12. 

8  "  On  Certain  Condition!  of  Nervous  Derangement,"  New  York,  1881. 


734 


CEREBRO-SPINAL   DISEASES. 


Alterations  of  Motility. — These  may  be  evidenced  in  the  way  of 
paralysis  or  of  clonic  or  tonic  spasm. 

Hysterical  paralysis  has  long  been  known,  and  is  quite  a  common 
manifestation  of  the  affection.  It  may  appear  in  the  character  of  hemi- 
plegia, paraplegia,  or  of  much  more  restricted  extent.  I  have  a  case, 
now  under  care,  in  which  it  is  limited  to  the  index-finger,  and  I  have 
had  several  in  which  a  single  muscle  of  the  eyeball,  or  in  which  the  leva- 
tor palpebral  superioris,  was  alone  affected. 

Hysterical  aphonia  is  due  to  paralysis  of  one  or  more  muscles  of  the 
larynx.  Like  the  loss  of  power  in  other  muscles  from  a  similar  cause, 
it  often  comes  on  very  suddenly,  and  as  suddenly  disappears. 

Paraplegia,  hysterical  in  its  character,,  may  be  partial  or  complete 
as  regards  a  muscle,  group  of  muscles,  or  a  limb.  When  incomplete, 
the  patient,  if  it  involves  the  lower  extremities,  drags  her  limbs  slug- 
gishly along,  or  shuffles  her  foot  over  the  floor,  using  a  cane  or  crutches 
or  holding  on  to  articles  of  furniture  that  may  be  in  the  room.  There 
is  nothing  about  the  gait  like  that  of  locomotor  ataxia  or,  in  fact,  of 
any  other  of  the  diseases  of  the  cord  already  considered  ;  and  careful 
observation  will  generally  reveal  the  fact  that,  during  one  interview 
and  examination,  the  patient  walks  very  unequally,  according  to  the 
state  of  her  mind  at  the  time,  or  the  influences  which  act  upon  her. 

Spasms  may  be  either  tonic  or  clonic,  and  may  affect  any  muscle  of 
the  body.  In  the  pharynx,  tonic  spasm  causes  the  sensation  to  which 
the  term  globus  liystericus  is  applied,  and  which  gives  rise  to  the  sen- 
sation of  a  ball  in  the  throat.  In  the  oesophagus,  spasm  may  continue 
for  a  long  time,  and  may  thus  simulate  stricture.  It  may  also  be  seated 
in  the  stomach,  intestines,  or  bladder. 


Fig.  102. 


In  the  limbs  spasm  of  the  tonic  character  causes  contraction,  and 
thus,  especially  when  combined  with  paralysis,  may  give  the  appear- 


HYSTERIA.  735 

ance  of  organic  lesion.  I  have  frequently  known  hysterical  contrac- 
tions to  last  several  months  at  a  time,  and  have  had  many  cases  of  the 
kind  under  my  charge  in  which  the  actual  cautery  had  been  applied 
to  the  back  for  supposed  inflammation  of  the  cord. 

In  some  cases  the  duration  is  even  longer  than  this.  Charcot 
cites  an  instance  in  which  a  woman,  aged  fifty-five,  was  seized,  eight- 
een years  previously,  with  a  hysterical  paroxysm  followed  by  para- 
plegia and  contraction.  At  first  this  latter  phenomenon  disappeared 
from  time  to  time  to  reappear  again  and  again,  but  for  the  past  six- 
teen years  there  had  been  no  change.  The  extensors  and  adductors, 
as  will  be  seen  from  the  accompanying  woodcut  (Fig.  102),  are  the 
muscles  mainly  affected.  The  muscles  of  the  legs  and  thighs  were 
notably  atrophied,  and  the  faradaic  contractility  was  lessened.  For 
several  years  this  patient  had  ceased  to  exhibit  hysterical  phenomena. 

The  subject  of  permanent  hysterical  contraction  is  well  considered 
by  MM.  Bourneville  and  Voulet,1  and  the  foregoing  case  is  detailed  at 
length  in  their  memoir.  In  such  instances  there  is  probably,  as  in 
Case  XIII.  of  their  work,  in  which  there  was  a  post-mortem  examina- 
tion, and  which  has  already  been  cited  in  this  treatise  (page  551), 
symmetrical  lateral  spinal  sclerosis. 

Clonic  spasms  simulate  chorea  or  epilepsy.  They  are  especially 
common  among  the  women  who  attend  spiritualistic  gatherings,  and 
indeed  I  have  seen  several  cases  at  such  places  among  the  weak-minded 
men  who  believe  in  the  nonsense  called  spiritualism. 

The  functional  actions  of  the  viscera  are  exceedingly  liable  to  de- 
rangement in  hysteria.  Any  organ  of  the  body  may  be  affected,  but 
the  stomach  appears  to  be  the  favorite  one.  There  may  be  obstinate 
vomiting,  or  persistent  flatulence,  or  acidity,  or  indigestion  in  some 
other  form  ;  or  the  bowels  may  be  the  seat,  giving  rise  to  intestinal  in- 
digestion, diarrhoea,  or  obstinate  costiveness  ;  or  the  kidneys  may  be 
involved,  and  there  may  be  an  enormous  secretion  of  pale,  limpid  urine, 
or  the  quantity  may  be  reduced  to  a  minimum  ;  or  the  uterus  or  the 
ovaries  may  be  the  seat.  Not  infrequently  organic  disease  of  the  heart 
is  simulated,  there  being  palpitation  and  general  irregular  action  of 
this  organ. 

Besides  these  several  manifestations  of  hysteria,  there  are  parox- 
ysms of  the  disease,  characterized  by  emotional  disturbance,  spasm, 
convulsions,  partial  loss  of  consciousness,  and  sometimes  coma.  All 
these  phenomena  may  be  manifested  during  an  attack,  or  a  Beizure  ma y 
consist  of  any  one  or  more  of  them.  The  convulsions  sometimes  bear 
a  resemblance  to  epilepsy,  sometimes  to  tetanus,  sometimes  t<>  hydro- 
phobia, sometimes  to  catalepsy,  sometimes  to  chorea.  But,  though 
simulating  these  diseases,  the  essentially  hysterical  paroxysm  can  bo 
readily  distinguished  from  either  of  them,  mainly  by  the  facts  of  its 
1  "De  la  contraction  hystfoique  permanento,"  Paris,  1872. 


736  CEREBRO-SPINAL   DISEASES. 

lack  of  consistency,  the  absence  of  the  constitutional  disturbance 
which  attends  the  others,  and  by  the  presence  of  emotional  excite- 
ment, and  the  consequent  irrational  laughing  or  crying.  Attention 
will  be  again  directed  to  some  of  these  conditions  in  the  ensuing 
chapter. 

Mania  may  be  simulated,  but  the  false  can  scarcely  be  mistaken  for 
the  real  disease  by  any  practitioner  with  his  wits  about  him. 

Causes. — Of  the  predisposing  causes,  sex  stands  first.  Of  the  many 
cases  of  hysteria  which  have  been  under  my  charge  or  seen  by  me  in 
consultation,  but  four  were  in  males.  In  one  of  these  the  affection 
was  apparently  induced  by  excessive  study,  and  was  characterized  by 
frequent  paroxysms  of  laughing  and  crying.  One  was  a  physician, 
and  the  disease  took  the  form  of  coma ;  one  was  a  lawyer  in  this  city, 
the  disease  in  him  simulating  epilepsy  ;  and  the  fourth  was  a  shop- 
keeper from  New  Jersey,  who  had  tetanoid  paroxysms  attended  with 
fits  of  sobbing,  crying,  and  laughing,  and  in  whom  it  was  excited  by 
masturbation. 

But,  while  there  is  this  great  predominance  of  females  as  the  sub- 
jects of  hysteria,  I  do  not  believe  that  the  fact  is  always  due  to  any 
particular  influence  of  the  uterus  or  other  generative  organs.  It  is 
probably  the  result  in  many  instances  of  the  delicacy  of  organization, 
and  the  greater  development  of  the  emotional  system,  acted  upon  by 
the  exciting  causes  to  be  presently  mentioned. 

Age  is  another  predisposing  cause.  The  period  of  life  at  which 
hysteria  is  most  common  is  that  extending  from  sixteen  to  twenty-five. 
After  the  latter  age  there  is  a  gradual  decline  until  the  age  is  reached 
at  which  the  menstrual  function  begins  to  become  irregular,  and  then 
the  number  of  cases  increases. 

The  civil  condition,  as  regards  marriage  or  celibacy,  is  to  be  taken 
into  consideration  among  the  predisposing  causes.  Undoubtedly  the 
disease  is  much  more  frequent  among  the  single  than  the  married,  but 
it  is  by  no  means  confined  to  them.  In  my  opinion  the  increased  pro- 
clivity of  single  women  to  hysteria  is  not  to  be  attributed  to  ungrati- 
fied  sexual  desires,  or  even  to  the  non-fulfillment  of  the  functions  of 
the  generative  organs,  but  rather  to  that  lack  of  aims  in  life,  and  the 
consequent  reflection  of  the  thoughts  and  emotions  upon  self,  which  are 
so  inseparably  connected  with  the  present  condition  of  single  women. 
Certainly  those  celibates  who  have  made  for  themselves  objects  in  ex- 
istence are  no  more  subject  to  hysteria,  in  my  experience,  than  married 
women.  Want  of  occupation  is  one  of  the  powerful  predisposing  causes 
of  hysteria,  and  it  is  to  a  great  extent  through  the  direct  influence  of 
this  factor  acting  upon  a  more  impressionable  organization  that,  in  my 
opinion,  hysteria  is  more  common  in  women  than  in  men.  In  those 
savage  and  semi-savage  countries  where  women  work,  hysteria  is  un- 
heard of..    It  used  to  be  almost  unknown  among  the  negro  women  in 


HYSTERIA.  737 

the  South,  but  since  their  emancipation,  if  my  inquiries  have  ascertained 
the  truth,  it  is  becoming  quite  common  among  them. 

Hereditary  influence  is  undoubtedly  an  important  predisposing  cause 
of  hysteria.  My  own  statistics  are  not  complete  on  this  point,  but  they 
are  full  enough  to  show  that  the  majority  had  either  hysterical  mothers, 
aunts,  or  grandmothers,  and  many  of  the  others  had  relatives  affected 
with  other  nervous  diseases.  Briquet  speaks  very  emphatically  of  the 
decided  influence  of  hereditary  tendency  as  deduced  from  his  inquiries. 

The  luxurious  habits  of  life  attendant  upon  refinement  and  educa- 
tion conduce  to  the  development  of  hysteria.  Attendance  at  theatres 
and  operas,  the  cultivation  of  music,  the  reading  of  poetry  and  novels, 
the  study  of  art,  and  any  other  influence  capable  of  developing  the  emo- 
tional system  at  the  expense  of  the  purely  physical  or  intellectual,  fa- 
vor the  growth  of  hysterical  tendencies. 

Of  exciting  causes,  sudden  emotional  disturbance  ranks  first.  Arjx- 
iety,  grief,  disappointment,  the  intense  desire  of  self-gratification,  a  fit 
of  ill-temper,  with  other  similar  factors,  often  induce  paroxysms  of  the 
disease.  Mental  or  physical  fatigue,  menstrual  derangement,  or  uterine 
or  ovarian  disorders,  may  also  act  as  exciting  causes. 

But  probably,  above  all  these,  is  the  contagion  set  in  action  by  the 
contact  with  a  hysterical  person.  I  have  seen  a  whole  hospital  ward 
of  women  thrown  into  paroxysms  of  hysteria  by  one  patient  suffering 
from  an  attack. 

Diagnosis. — To  detail  the  diagnostic  marks  which  distinguish  hys- 
teria from  other  diseases  would  require  more  space  than  is  proper  in  a 
work  like  the  present,  and  would,  moreover,  be  rather  a  work  of  super- 
erogation. The  physician  has  simply  to  recollect  that  all  hysterical 
affections  have  a  family  resemblance,  and  that,  although  almost  every 
known  disease  may  be  simulated,  yet  that  the  counterfeit  is  never  a 
good  one.  Attention  to  the  symptoms  of  the  several  diseases  already, 
and  to  be  described,  with  a  careful  observation  of  the  case,  and  due 
inquiry  into  the  antecedents  of  the  patient,  will  prevent  a  mistake  be- 
ing  made. 

He  must  also  recollect  that  the  hysterical  patient  always  tries  to 
impress  others  with  the  belief  thai  she  is  very  ill.  She  craves  sym- 
pathy, and  Feeds  on  it  with  the  effect  of  nourishing  her  disease.  If  she 
can  cajole  her  medical  attendant  by  appealing  to  his  kindly  emotions, 
will  <]o  it,  but  failing  in  this  she  will  try  her  power  o\er  his  fears, 
and  will  Leave  no  stone  unturned  to  deceive  him.  Careful  watching, 
with  thorough  skepticism,  will  either  result  in  her  detection,  or  in  her 
defeat  Erom  Bheer  weariness. 

Prognosis.— As  regards  the  prospect  of  recovery  from  any  particular 
manifestation  of  hysteria,  or  from  a  paroxysm  of  any  kind,  the  ; 
nosi-   1^  favorable,  provided  proper  treatment  be  employed,  but,  as  re- 
gards the  liability  to  further  attacks,  much  depends  on  the  (riroum- 

48 


738  CEREBRO-SPINAL   DISEASES. 

6tances  which  surround  the  patient  and  the  time  during-  which  she  has 
been  subject  to  the  affection.  If  she  can  be  submitted  to  proper  treat- 
ment, without  the  interference  of  herself  or  her  friends,  the  prospect  of 
recovery,  even  in  bad  cases,  is  good  ;  but  if  she  is  to  be  allowed  to  do 
as  she  pleases,  or  if  injudicious  friends  are  constantly  lavishing  the  sym- 
pathy and  mistaken  kindness  which  keep  her  disease  alive,  there  is  not 
much  use  in  medicine  or  hygiene,  and,  as  Reynolds  says,  the  "  case  is 
hopeless,  and  might  as  well  be  left  alone." 

Morbid  Anatomy  and  Pathology. — Hysteria  contributes  absolutely 
nothing  to  the  science  of  morbid  anatomy.  The  brain,  the  spinal  cord, 
the  sympathetic  nerve,  give  no  evidence  of  its  former  presence.  It  is 
true,  hysteria  very  rarely  causes  death,'  but  hysterical  patients  have 
died  of  intercurrent  affections,  and  post-mortem  examinations  have  been 
made,  and  nothing  which  could  reasonably  be  regarded  as  the  essential 
cause  of  the  disease  has  been  found.  Several  of  the  older  writers  im- 
agined that  they  had  discovered  the  lesion  in  the  genital  organs,  in  the 
stomach  and  intestines,  in  the  brain,  and  even  in  the  spleen  ;  but  mod- 
ern research  teaches  us  differently.  At  present,  then,  we  are  in  total 
ignorance  of  the  character  of  the  lesion.  From  the  symptoms,  which 
are  so  obviously  indicative  of  disordered  brain  and  spinal  cord,  I  have 
felt  myself  justified  in  classing  it,  provisionally  at  least,  among  the  cere- 
brospinal diseases. 

The  pathology  or  morbid  physiology  of  hysteria  is  beginning  to  be 
better  understood  as  our  knowledge  of  the  cerebral  and  spinal  actions 
becomes  more  complete.  Looking  at  the  brain  as  a  complex  organ  evolv- 
ing a  complex  force — the  mind — we  can  understand  the  possibility  of 
certain  parts  of  it  becoming  disordered,  as  regards  excess,  diminution, 
or  quality,  in  the  results  of  their  actions.  We  have  seen,  under  the 
head  of  insanity,  that  the  mind  is  made  up  of  certain  sub-forces — the 
perception,  the  intellect,  the  emotions,  and  the  will — and  that  these, 
when  disordered,  constitute  varieties  of  insanity,  which  are  easily  recog- 
nized. 

Hysteria  essentially  consists  in  the  predominance  of  the  emotions 
over  the  intellect,  and  especially  over  the  will,  and  this  exaltation  may 
be  so  intense  as  to  interfere  with  the  sensibility  of  various  parts  of  the 
body,  or  to  derange  the  contractility  of  muscles. 

At  the  same  time,  in  the  paroxysms  of  the  disease,  the  reflex  and 
automatic  functions  of  the  spinal  cord  are  involved  to  a  great  extent. 

We  daily  witness  examples  of  the  influence  of  emotions  on  sensi- 
bility and  motility.  Fear  renders  the  sensibility  more  acute  and  pro- 
duces trembling,  which  is  simply  clonic  spasm  ;  grief  causes  tonic  con- 
tractions of  the  muscles  ;  surprise,  terror,  or  horror,  paralyzes  them  ; 
joy  or  anger  destroys  sensibility  to  pain,  and  so  on. 

At  the  same  time  that  there  is  this  exaltation  of  emotional  power  in 
hysteria,  the  power  of  the  will  is  not  only  relatively  but  is  absolutely 
diminished.    The  two  factors,  acting  together  steadily  and  persistently, 


HYSTERIA.  739 

induce  many  of  the  manifestations  of  hysteria.  The  disease  is,  there- 
fore, a  partial  insanity — an  insanity,  however,  in  which  the  patient  does 
not  entirely  lose  the  power  of  control,  and  which  is  capable  of  being 
overcome  by  the  voluntary  effort  of  the  patient,  provided  a  sufficient 
stimulus  to  normal  volition  be  brought  to  bear.  It  thus  happens  that, 
through  the  influence  of  such  stimulus,  every  symptom  of  hysteria  dis- 
appears as  if  by  magic. 

The  spinal  cord  is  often  secondarily  affected,  and  it  is  likewise  fre- 
quently primarily  involved.  The  gray  or  the  white  substance,  the  pos- 
terior or  the  antero-lateral  columns  may  be  implicated,  the  symptoms 
varying  accordingly.  Through  the  spinal  cord,  in  its  abnormal  condi- 
tion, we  have  the  convulsions  of  various  kinds,  the  spasms,  contrac- 
tions, and  the  paraplegic  and  hemiplegic  phenomena  connected  with 
motion  and  sensation. 

As  to  the  influence  of  the  vaso-motor  system,  though  I  admit  its 
existence,  I  am  convinced  that  it  is  simply  a  link  in  the  chain,  and  is 
secondary  to  the  emotional  disturbance  already  mentioned. 

Treatment. — No  cases  are  so  well  calculated  to  test  the  patience  and 
tact  of  the  physician  as  those  of  hysteria.  For  he  has  an  affection  to 
deal  with,  which  not  only  requires  proper  medical  treatment,  but  in 
which  he  must  often  exert  the  highest  mental  qualities,  in  order  to  cure 
the  disease.  A  great  deal,  therefore  depends  on  the  knowledge  of  hu- 
man nature  and  the  force  of  character  of  the  physician  ;  and  it  is  doubt- 
less owing  to  this  fact  that  some  physicians,  with  all  their  medical 
knowledge,  fail  in  curing  hysterical  affections,  while  others,  with  no 
superior  science,  succeed  at  once. 

The  first  thing  to  be  done  is  to  gain  the  confidence  and,  what  is  of 
still  greater  importance,  the  respect  of  the  patient.  Having  done  this, 
any  treatment,  moral  or  medical,  calculated  to  relieve  her,  will  be  much 
more  apt  to  produce  the  desired  effect. 

During  the  period  between  the  paroxysms,  the  treatment  must  be 
directed  mainly  against  symptoms.  If  the  patient  can  be  made  to  be- 
lieve that  her  case  is  thoroughly  understood,  and  that  she  is  not  sus- 
ed  of  shamming,  and  that,  with  her  assistance,  the  hypenesthesia, 
or  anesthesia,  or  paralysis,  will  be  removed,  the  effect  which  is  desired 
will  probably  be  produced.  For  putting  a  hysterical  patient  into  a 
proper  frame  of  mind,  I  know  of  nothing  equal  to  i  he  bromides,  of  either 
potassium,  sodium,  calcium,  or  zinc,  given  in  large  doses,  repeated  three 
ur  four  times  a  daj .  nil  the  full  effeol  La  obtained.  This  will  generally 
relieve  hyperesthesia  wherever  it  may  be  seated,  and  the  influence  over 
the  mental  phenomena  of  the  disease  is  usually  very  decidedly  shown. 

If  anesthesia  be  the  prominent  condition,  electricity  is  to  be  used, 
and  it  is  almost  a  specific.  I  have  never  seen  a  case  of  hysterical  an- 
BBSthi  i   it.     A  few  days  ago,  I  was  consulted  by  a  young  ladv 

who  was  entirely  anesthetic  over  the  whole  of  the  Burfaoe  of  one  Bide 
of  the  body,  and  who  had  Buffered  for  several  weeks.     Three  applioa- 


740  CEREBROSPINAL   DISEASES. 

tions  of  the  induced  current  through  the  wire  brush,  which  was  passed, 
at  each  seance,  over  the  whole  anaesthetic  region,  entirely  cured  her. 

For  hysterical  paralysis,  strychnia  and  phosphorus  are  the  best  in- 
ternal reiuedies.  They  may  be  taken  together  in  the  form  recommended 
on  page  68,  and  rarely  fail  to  produce  a  cure.  Their  effect  is,  how- 
ever, greatly  increased  by  the  use  of  electricity,  both  of  the  primary 
and  induced  forms — the  first  being  applied  to  the  spine,  and  the  latter 
to  the  paralyzed  muscles. 

In  cases  of  spasm,  I  prefer  the  bromides,  internally,  and  the  primary 
galvanic  current,  applied  to  the  contracted  muscles. 

Visceral  derangements  are  best  treated  by  strychnia  and  phospho- 
rus, as  recommended  for  paralysis.  Counter-irritation,  in  the  form  of 
blisters,  is  almost  always  of  service.  For  gastric  troubles,  the  subear- 
bonate  of  bismuth,  in  doses  of  fifteen  or  twenty  grains,  after  each  meal, 
will  generally  prove  of  service.  In  a  very  obstinate  case  of  hysterical 
vomiting  under  my  charge,  everything  failed  but  hydrocyanic  acid. 

Recently,  in  several  extreme  cases  of  hysterical  vomiting,  and  nota- 
bly in  one  I  saw  in  consultation  with  Dr.  C.  T.  Whybrew,  I  have  ob- 
tained very  prompt  results  from  the  valerianate  of  caffeine  in  doses  of 
three  grains  repeated  in  a  half-hour  if  necessary.  Paret1  adduces  sev- 
eral examples  of  its  beneficial  effects  in  like  cases. 

In  other  cases  I  have  arrested  hysterical  vomiting  by  giving  four 
or  five  pills  of  hydrochlorate  of  cocaine,  each  pill  containing  the  one 
twentieth  of  a  grain  of  the  drug. 

Hysterical  paroxysms  are  best  treated  with  ether  or  chloroform,  ad- 
ministered by  inhalation.  I  have  repeatedly  used  the  hydrate  of  chlo- 
ral, but  it  has  not  in  my  hands  been  as  speedy  or  as  effectual  in  it3 
action  as  either  of  the  other  agents.  I  give  them  to  the  extent  of  pro- 
ducing complete  insensibility,  and  repeat  them  again  and  again,  if  there 
are  any  evidences  of  a  return  of  the  seizure.  Whether  in  the  purely 
emotional  paroxysms  or  those  characterized  by  muscular  spasms  of 
various  kinds,  or  any  possible  combination,  nothing  is  equal,  according 
to  my  experience,  to  ether  or  chloroform  by  inhalation.  I  have  tried 
every  other  known  means,  from  cold  water,  dashed  in  the  face,  to 
moral  suasion,  and  none  of  them  are  comparable  to  ether  or  chloroform. 

I  have  also  found  decided  benefit  from  the  mono-bromide  of  cam- 
phor in  breaking  up  what  may  be  called  the  status  hystericus.  In  a 
recent  communication 2  I  called  attention  to  its  good  effects  in  such 
cases.  It  may  be  given  in  pill  or  emulsion  in  doses  of  from  three  to 
five  grains  every  hour  or  two,  as  may  be  required.  In  those  cases  in 
which  ether  or  chloroform  is  contraindicated  the  mono-bromide  of  cam- 
phor is  particularly  valuable. 

1  "  De  l'emploi  de  valerianate  de  cafcine,''  Paris,  1875. 

2  "Note  relative  to  the  Mono-Bromide  of  Camphor,"  New  York  Medical  Journal,  vol 
xiii.,  1871. 


HYSTERIA.  t  741 

But,  for  the  dissipation  of  the  hysterical  tendency,  long-continued 
treatment  is  necessary.  Medicines  which  are  ordinarily  regarded  as 
antispasmodics,  such  as  valerian,  asafoetida,  musk,  and  the  like,  I  have 
never  seen  produce  any  benefit  in  any  form  of  hysteria,  and,  for  the 
purpose  of  causing  any  radical  change  in  the  organism,  they  are  worse 
than  useless.  As  medicines  for  this  object,  I  know  of  nothing  superior 
to  phosphorus,  in  some  one  of  its  forms,  and  strychnia.  They  should  be 
taken  for  months  in  small  doses,  and  should  be  supported  by  all  hy- 
gienic measures  calculated  to  improve  the  tone  of  the  system.  Travel 
is  of  inestimable  advantage,  and,  above  all,  association  with  persons  of 
both  sexes,  whose  intellects  control  their  emotions,  and  who  are  en- 
dowed with  sound  common-sense  and  that  tact  and  knowledge  of  human 
nature  which,  for  the  purposes  of  every-day  life,  are  of  more  value  than 
many  other  qualities  often  ranked  above  them. 

It  is  very  certain  that  in  most  cases  of  hysteria  the  exhibition  of 
sympathy  is  exceedingly  injudicious  and  is  generally  taken  advantage 
of  by  the  patient  to  impose  still  further  on  those  around  her.  Thus  a 
lady  to  whom  I  was  called  had  gotten  into  a  morbid  condition  attended 
with  frequent  paroxysms  of  weeping,  because,  as  she  said,  she  no  longer 
cared  for  her  husband  or  children,  and  that  she  wished  they  were  dead, 
etc.  All  the  arguments  of  her  friends  failed  to  convince  her  that  she 
was  a  good  wife  and  mother,  but,  on  my  telling  her  husband  in  her  pres- 
ence that  I  was  afraid  it  would  be  necessary  to  send  her  to  a  lunatic 
asylum,  her  interest  was  at  once  awakened,  and  the  next  morning  she 
was  entirely  free  from  all  hysterical  phenomena.  She  subsequently 
told  me  that  nothing  had  roused  her  but  the  fear  of  being  put  in  a 
hospital  for  the  insane. 

In  another  case  a  lady  had  terrified  her  friends  and  excited  the 
greatest  commotion  by  threatening  to  put  an  end  to  her  life  by  jump- 
ing out  of  the  window.  When  I  saw  her  she  was  strapped  down  to  a 
bed  and  was  being  supplicated  by  half  a  dozen  people  in  the  room  not 
to  kill  herself,  to  which  she  was  energetically  replying  that  she  would. 
I  loosened  the  straps,  opened  the  window,  and  told  her  to  jump  out. 
She  walked  to  the  window,  looked  out  for  a  moment,  and  then,  apply- 
ing no  very  politeepithet  to  me,  went  back  to  bed,  and  I  heard  no  more 
of  her  suicidal  desires. 

A  still  more  remarkable  case  is  given  by  M.  Charcot.'  The  pa- 
tient, a  woman,  had  been  for  at  least  four  years  the  subject  of  con- 
traction of  one  of  the  lower  extremities,  as  shown  in  the  woodcut 
(Fig.  1<>:5).  In  consequence  of  her  insubordination  on  one  occasion,  he 
spoke  to  her  very  sharply,  and  threatened  to  send  her  out  of  the  hos- 
pital. The  m\t  morning  the  contraction  had  entirely  disappeared.  In 
the  face  of  facts  like  these  ii  appears  absurd  to  invoke  supernatural 
agencies. 

1  "Lemons  sur  lcs  maladies  du  lyatdme  oerveux,"   Paris,  IS72-'73,  p.  31S. 


742 


CEREBRO-SPINAL   DISEASES. 


It  is,  perhaps,  scarcely  necessary  to  state  that  the  society  of  other 
hysterical  persons  must  be  rigidly  eschewed,  and  that  even  the  casual 
meeting  with  such  individuals  is  dangerous. 


Fro.  103. 


CHAPTER  VI. 

HYSTEROID  AFFECTIONS— CATALEPSY,   ECSTASY,  HYSTERO-EPILEPSY. 

There  are  certain  disorders  so  very  like  hysteria  in  some  of  its 
manifestations,  and  often  existing  with  it  in  the  same  individual,  that 
they  might  with  propriety  have  been  considered  in  the  last  chapter,  es- 
pecially as  by  some  high  authorities  the  scope  of  hysteria  is  so  enlarged 
as  to  be  made  to  embrace  them  within  its  limits.  But,  though  they 
may  owe  their  existence  to  the  same  peculiar  condition  of  the  nervous 
system,  to  which  the  ordinary  phenomena  of  hysteria  are  due,  there 
is  sufficient  individuality  about  them  to  warrant  their  being  studied 
separately.  At  the  same  time  there  will  be  no  difficulty  in  our  bearing 
in  mind  that  they  are  decidedly  of  such  general  and  special  character- 
istics as  to  impress  us  very  forcibly  with  the  idea  that  they  are  essen- 
tially hysterical.  We  may,  therefore,  with  propriety,  class  them  to- 
gether in  the  present  chapter  as  hysteroid. 


CATALEPSY. 


Although  there  are  no  post-mortem  appearances  characteristic  of 
catalepsy,  the  phenomena  of  the  disease  observed  during  life  point  to 


CATALEPSY.  743 

its  seat  in  the  brain  and  spinal  cord.  Like  epilepsy,  therefore,  it  is 
a  symptom  representing  an  unknown  morbid  change  in  the  nervous 
centres. 

Symptoms. — Catalepsy  is  an  affection  marked  by  the  occurrence  of 
peculiar  paroxysms  at  regular  or  irregular  periods.  The  seizures  usu- 
ally come  on  with  suddenness,  and  are  characterized  by  more  or  less 
complete  suspension  of  mental  action  and  of  sensibility,  and  by  the 
supervention  of  muscular  rigidity,  causing  the  limbs  to  retain,  for  a 
long  time,  any  position  in  which  they  may  be  placed.  The  phenomena, 
therefore,  relate  to  the  mind,  to  sensation,  and  to  motion. 

The  suspension  of  mental  action  is,  in  general,  complete,  but  in  some 
cases  there  are  an  imperfect  consciousness  and  an  ability  to  appreciate 
strong  sensorial  impressions.  Thus,  in  a  case  quoted  by  Dr.  Chambers 
from  Dr.  Jebb — which,  however,  was  clearly  a  case  of  catalepsy  compli- 
cated with  hysteria — the  patient,  before  emerging  from  the  paroxysm, 
sang  "  three  plaintive  songs  in  a  tone  of  voice  so  elegantly  expressive, 
and  with  such  affecting  modulation,  as  evidently  pointed  out  how  much 
the  most  powerful  passion  of  the  mind  was  concerned  in  the  production 
of  her  disorder,  as  indeed  her  history  confirmed."  l 

The  aspect  of  a  cataleptic  patient  is  very  striking.  The  eyelids  are 
sometimes  wide  open,  at  others  gently  closed  ;  the  pupils  are  dilated, 
and  do  not  respond  to  strong  light ;  the  respiration  is  slow,  regular,  but 
generally  so  feeble  as  to  be  perceived  with  difficulty;  the  pulse  is  usu- 
ally almost  imperceptible,  but  is  rhythmical  and  sluggish  ;  the  face  is 
pale,  the  mouth  is  half  open,  and  the  rigidity  of  the  body  and  the  cold- 
ness of  the  extremities  add  to  the  death-like  appearance  which  im- 
presses all  beholders. 

The  cutaneous  sensibility  is  ordinarily  completely  abolished.  Pins 
may  be  stuck  into  the  skin,  and  they  are  not  felt  ;  but,  owing  to  the 
abolition  of  the  power  of  motion  and  of  reflex  action,  it  is  possible  that 
in  some  cases,  at  least,  the  patients  would  give  evidence  of  sensation  if 
they  could.  Cases  are  on  record  in  which  tears  have  been  caused  by 
excessive  emotional  disturbance  excited  by  the  words  or  actions  of  per- 
sons surrounding  the  patients,  thus  showing  that  the  senses  of  sight  and 
hearing  were  capable  of  being  exercised.  Such  instances  are,  however, 
rare,  and  are  probably  imperfectly-developed  paroxysms,  or  those  com- 
plicate ■(  I  with  hysteria  or  ecstasy. 

The  symptoms  relating  to  the  muscles  arc  very  remarkable.  Com- 
ing on,  as  the  paroxysm  usually  does,  without  warning  <>t'  any  kind,  the 
patient  is  at  once  arrested  in  any  act  which  is  being  performed,  and  the 
whole  body  assumes  a  oondition  of  extreme  rigidity.  The  power  of  the 
will  over  the  muscles  is  lost,  and  the  limbs  preserve  any  position  in 
which  tiny  may  be  placed  by  the  by-standcrs.  Thus,  if  the  arm  be 
raised  from  the  side,  it  remains  extended,  and  may  keep  this  position 
1  Article  "  Catalepsy,"  in  Reynolds's  "System  of  Medicine,"  vol.  ii.,  j>.  L(XX 


744  CEREBRO-SPINAL  DISEASES. 

for  an  hour  or  longer  before  it  sinks  slowly  back  to  its  original  situ« 
Mion.  No  matter  how  awkward  or  irksome  the  position  may  be,  it 
is  retained  till  the  exalted  irritability  of  the  muscles  becomes  thorough- 
ly exhausted. 

The  ability  to  swallow  is  not  lost,  and  the  electric  contractility  of 
the  muscles  is  not  perceptibly  affected  one  way  or  the  other. 

The  paroxysm  may  last  a  few  minutes  or  hours,  or  may  be  prolonged 
to  several  days. 

The  temperature  of  the  body,  in  all  the  cases  that  have  come  under 
my  observation,  was  reduced  from  two  to  four  degrees  below  the  nor- 
mal standard,  and  in  the  extremities  much  more  than  this. 

The  paroxysm  generally  disappears  with  as  much  abruptness  as 
marked  its  accession.  A  few  deep  inspirations  are  taken,  the  eyes  are 
opened,  or  lose  their  fixedness,  the  muscles  relax,  and  consciousness  is 
restored.  In  fully-developed  seizures  the  patient  has  no  knowledge  of 
what  has  occurred  during  the  attack. 

Ten  cases  of  true  catalepsy,  uncomplicated  either  with  hysteria  or 
ecstasy,  have  been  under  my  professional  care.  In  two  of  these  the 
seizures  were  more  or  less  imperfectly  developed,  and  strong  sensorial 
excitations  were,  in  a  measure,  perceived  and  recollected  after  emer- 
gence from  the  attack.  But  in  every  instance  the  character  of  the  im- 
pression was  misinterpreted.  A  bright  light  thrown  upon  the  eyes 
with  a  mirror  was  spoken  of  as  an  "  angel's  wing  which  brushed  across 
my  face,"  and  the  scratch  of  a  pin  was  remembered  as  "  a  piece  of  ice 
being  drawn  over  the  skin." 

In  these  cases  there  was  the  consciousness  of  mental  action  during 
the  paroxysm,  but  it  was  difficult  for  the  patients  to  describe  the 
thoughts  which  took  place.  They  appeared  to  be  somewhat  of  the 
nature  of  dreams.  In  both  cases  the  muscular  rigidity  was  well  marked 
but  was  not  excessive,  and  appeared  to  be  mainly  manifested  in  the  ex- 
tensors. It  was  not  difficult  to  extend  the  arm  or  the  leg,  but  flexion 
required  the  exertion  of  a  good  deal  of  strength. 

In  the  other  eight  cases  the  paroxysms  were  completely  formed. 
Consciousness  was  entirely  abolished  ;  there  was  no  sensibility  any- 
where, and  no  reflex  actions  could  be  excited  except  those  of  degluti- 
tion. In  one  of  these  cases,  seizures  several  times  occurred  in  my  con- 
sulting-room, .and  I  had  the  opportunity  of  ascertaining  the  effect  of 
electricity.  If  the  arm  was  extended,  the  strongest  induced  current  I 
could  apply  to  the  biceps,  though  causing  contraction,  failed  to  procure 
flexion,  but  relaxation  of  the  extensors  was  at  once  produced  by  the 
application  to  them  of  the  galvanic  current. 

I  likewise,  in  this  case,  repeatedly  examined  the  fundus  of  the  eye 
with  the  ophthalmoscope,  and  invariably  found  the  choroids  pale,  and 
the  retinal  vessels  straight  and  attenuated. 

In  none  of  these  cases  was  there  any  knowledge  of  what  passed 


CATALEPSY.  ?4o 

during  the  paroxysms,  and  no  consciousness  of  there  having  been  any 
mental  activity. 

Besides  these,  several  instances  have  occurred  in  my  experience  in 
which  cataleptic  phenomena  were  exhibited  in  the  course  of  other  dis- 
eases. In  one  of  them,  a  young  man  whom  I  saw  in  consultation  with 
Dr.  Max  Herzog,  of  this  city,  there  was  well-marked  mania — a  second 
attack.  On  my  entering  the  room  in  which  he  was  seated  I  observed 
that  he  had  a  rapt  expression  of  countenance,  and  that  his  limbs  were 
quiet,  and  apparently  rigid.  In  an  undertone  I  remarked  to  Dr.  Her- 
zog that  the  patient  had  a  somewhat  cataleptic  appearance.  Seizing 
his  arm  I  raised  it  from  the  body  and  it  remained  extended;  the  other 
arm  Avas  also  elevated  and  continued  in  that  position.  I  then  lifted 
the  legs  alternately  from  the  floor,  and  they  were  kept  in  their  appar- 
ently uncomfortable  positions.  During  the  consultation,  probably  a 
half-hour,  the  extremities  remained  as  I  had  placed  them.  A  few  days 
afterward,  he  became  so  violent  that  it  was  necessary  to  send  him  to  a 
lunatic  asylum. 

In  another  case  the  patient,  a  young  lady  of  this  city,  was  brought 
to  me  by  her  father  for  examination  and  advice.  As  she  entered  my 
consulting-room,  I  saw  that  there  was  a  high  degree  of  mental  exalta- 
tion present — her  eyes  were  raised  to  the  ceiling,  her  hands  were 
clasped,  and  her  lips  were  moving  as  if  in  prayer.  I  raised  her  left  arm 
from  the  body,  and  then  the  right  ;  both  remained  extended,  and  con- 
tinued so  till  I  changed  the  positions,  which  I  did  by  bending  the 
elbows,  bringing  them  to  the  front,  putting  them  behind  her,  and  so  on. 
I  then  again  extended  them,  and  she  left  the  house  with  them  in  this 
position;  but,  on  getting  into  the  street,  and  feeling  a  cold  wind  that 
was  blowing  at  the  time,  they  fell  to  her  side  and  she  began  to  use 
them  to  draw  her  shawl  around  her.  She  had  been  subject  to  epi- 
lepsy for  several  months,  but  had  never  before  exhibited  cataleptic 
phenomena. 

in  the  former  of  these  cases  there  was  no  possibility  of  ascertaining 
the  mental  associations  of  the  patient  with  the  muscular  rigidity;  in  the 
latter  the  patienl  said  thai  she  had  a  very  distinct  recollection  of  my 
extending  her  arms,  but  why  she  had  kept  them  so  she  did  not  know, 
and  thai  she  was  not  conscious  of  fatigue,  or  of  any  other  sensation. 

It  will  have  been  noticed  that  in  both  these  cases  the  paroxysms 
were  qo1  spontaneous,  but  were  excited  by  outside  interference. 

I'll.-  particulars  of  a  very  interesting  ease  of  catalepsy  have  been 
recently  given  to  me  by  Dr.  M.  B.  Early,  late  house-physician  to  Helle- 
vii.-  I  [ospital. 

The  patient,  a  I  terman,  a  oigar-maker,  aged  twenty-three,  bad  s.  rved 
In  the  army,  entered  the  hospital  October  4,1872.  In  the  previous 
July  he  had  been  drunk,  and,  quarreling  with  some  rough  people,  was 
severely  beaten  and  kicked  on  the  head  and  other  parts  of  his  body. 


746  CEKEBRO-SPINAL   DISEASES. 

On  the  27tb  of  September  he  had  an  attack  resembling  a  convul- 
sion. He  was  smoking  at  the  time,  and,  while  thus  engaged,  his  mother 
noticed  that  the  cigar  began  to  shake,  then  his  whole  body  quivered. 
She  attempted  to  take  the  cigar  from  his  mouth,  but  the  jaws  were 
tightly  closed,  and  the  cigar  was  bitten  through.  He  swallowed  the 
portion  that  was  left  in  his  mouth.  He  seemed  to  be  conscious,  for 
when  requested  by  his  mother  to  go  to  bed  he  shook  his  head.  He  did 
not  sleep,  but,  when  spoken  to,  nodded  or  shook  his  head  in  assent  or 
dissent  as  the  case  might  be.  He  did  not  foam  at  the  mouth  or  bite 
his  tongue.     His  feet  were  very  cold. 

The  attack  lasted  about  five  minutes.  He  then  vomited  the  piece  of 
cigar  he  had  swallowed,  and  went  to  bed,  sleeping  all  afternoon. 

The  following  day  he  had  a  similar  attack,  not  so  severe  as  the  first. 
During  the  five  following  days  he  was  free  from  paroxysms,  but  would 
not  talk,  although  he  ate  and  seemed  to  understand  what  was  said  to 
him,  and  would  do  any  little  thing  his  mother  requested.  On  the  sixth 
day,  soon  after  breakfast,  he  had  another  paroxysm,  but  of  a  different 
character  from  the  others.  While  the  previous  seizures  were  charac- 
terized by  tremor,  this  was  marked  by  a  rigidity  of  all  the  voluntary 
muscles  in  the  body.  The  attack  lasted  a  few  minutes,  and  the  next 
day  he  was  taken  to  the  hospital,  where  he  came  under  Dr.  Early's 
observation. 

On  admission,  October  4th,  he  lay  in  a  stupid  condition,  his  eyes 
sometimes  open  and  sometimes  closed.  Occasionally  he  looked  around, 
and  appeared  to  understand  what  was  said  to  him,  but  could  neither 
speak  nor  move.  The  pupils  were  dilated.  When  his  limbs  were 
placed  in  any  position  they  continued  there  for  a  considerable  period. 
The  muscles  were  rigid,  temperature  100°  Fahr. 

On  being  slapped  smartly  on  the  buttocks  with  a  book,  the  patient 
got  up,  looked  about  him,  and  walked  around  the  ward.  He  then  drank 
a  glass  of  milk  and  went  back  to  bed.  Just  before  getting  up  he 
smiled,  and  answered  a  question.  During  the  night  he  went  to  the 
water-closet.  In  the  morning  he  arose,  looked  around  him,  and  drank 
some  more  milk.  When  slapped  with  a  book  shortly  afterward,  he  did 
not  move  a  muscle;  seemed  more  stupid,  did  not  swallow  when  food 
was  placed  in  his  mouth,  and  apparently  did  not  feel  the  prick  of  a  pin. 

The  patient  continued  in  this  state  for  several  days.  On  the  12th 
he  was  photographed.  The  accompanying  woodcuts,  Figs.  104  and  105, 
show  the  positions  of  his  limbs  at  the  time. 

Under  the  treatment  the  patient  gradually  improved,  and  on  the  9th 
of  November  was  discharged  cured. 

An  ophthalmoscopic  examination,  made  November  3d,  showed  an 
anaemic  condition  of  the  disk. 

Cataleptic  persons  are  usually  of  dull  and  sluggish  mental  and  phys- 
ical  organization.      Such    has   certainly  been  the  case  in  all  the  in- 


CATALEPSY. 


747 


stances  that  have  come  under  my  observation.  The  disease  does  not 
ordinarily  show  any  decided  tendency  to  become  worse,  either  as 
regards  the  severity  or  frequency  of  the  paroxysms,  providing  the  ex- 
citing causes  be  avoided.      On  the  contrary,  there   is   often  a  well- 


Fig.  104. 


marked  natural  tendency  to  spontaneous  cure,  or  at  least  to  a  cure 
through  the  influence  of  purely  hygienic  influences,  moral  as  well  as 
physical. 

In  the  majority  of  cases  catalepsy  is  complicated  with  hysteria  or 


Fig.  103. 


ecstasy,  and  Bometimei  with  epilepsy.  Of  this  latter  combination  I 
have  seen  two  cases,  and  in  one  of  theso  eostasy  was  also  a  feature. 
This  case  I  have  alluded  to  in  another  communication.'     The  patient 

1  "The  rhvsics  and  PbytiologJ  of  Spiritualism,"  N'  w  York,  1S71,  p.  f>5. 


748  CEREBRO-SPINAL   DISEASES. 

was  a  young  girl,  was  cataleptic  on  an  average  once  a  week,  and 
epileptic  twice  or  three  times  in  the  intervals.  Five  years  previously 
she  had  spent  six  months  in  France,  but  had  not  acquired  more 
than  a  very  slight  knowledge  of  the  language — scarcely,  in  fact,  suffi- 
cient to  enable  her  to  ask  for  what  she  wanted  at  her  meals.  Immedi- 
ately before  her  cataleptic  seizures,  she  went  into  a  state  of  ecstasy, 
during  which  she  recited  poetry  in  French,  and  delivered  harangues 
about  virtue  and  godliness  in  the  same  language.  She  pronounced  at 
these  times  exceedingly  well,  and  seemed  never  at  a  loss  for  a  word. 
To  all  surrounding  influences  she  was  apparently  dead;  but  she  sat  bolt 
upright  in  her  chair,  staring  at  vacancy,  and  her  organs  of  speech  in 
constant  action.  Gradually,  she  passed  into  the  cataleptic  paroxysm, 
in  which  she  usually  remained  for  from  one  to  three  hours.  Many  cases 
of  the  combination  of  catalepsy  with  hysteria  and  ecstasy  have  become 
celebrated  in  other  relations  than  those  of  true  science. 

Causes. — Among  the  predisposing  causes,  sex  is,  in  my  experience, 
the  most  efficient,  though  other  writers  have  denied  any  influence  due 
to  sex.  Of  one  hundred  and  forty-eight  cases  cited  by  Puel,1  sixty- 
eight  were  males  and  eighty  females.  Seven  of  my  cases  were  in 
females.  Hereditary  influence  is  generally  apparent.  Of  the  ten  un- 
complicated cases  under  my  observation,  all  had  relatives  affected  with 
some  well-marked  disease  of  the  nervous  system.  In  four  cases,  there 
were  near  relatives  insane;  in  three,  the  mothers  were  hysterical;  in 
one,  a  brother  was  epileptic;  in  one,  the  father  was  similarly  affected; 
and,  in  one,  a  sister  was  cataleptic.  It  rarely  begins  after  the  age  of 
twenty-five.  Of  exciting  causes,  emotional  disturbance  stands  first. 
Four  of  my  cases  were  directly  the  result — one  of  fright,  one  of  anger, 
one  of  grief,  and  one  of  the  shock  caused  by  a  boy  starting  out  sud- 
denly from  behind  a  door  where  he  had  been  concealed.  In  one  other 
case,  the  cause  was  worms  in  the  intestinal  canal;  in  two,  business 
troubles;  in  one  a  severe  fall;  and,  in  the  other  two,  I  could  not  ascer- 
tain with  certainty  what  the  cause  was,  though  I  had  strong  reasons 
for  suspecting  it  to  be  masturbation. 

The  Diagnosis  is  not  a  matter  of  the  least  difficulty  to  any  one  who 
has  even  an  imperfect  knowledge  of  the  phenomena,  except,  perhaps, 
as  regards  its  discrimination  from  hysteria,  that  simulator  of  almost 
every  nervous  disease.  In  those  cases  complicated  with  hysteria,  the 
distinction  is  of  no  importance;  in  others,  the  uniformity  of  the  charac- 
teristics which  indicate  catalepsy,  with  a  consideration  of  the  general 
history  of  the  case,  will  serve  to  make  the  diagnosis  sufficiently  precise. 
It  must,  however,  be  borne  in  mind  that  the  two  diseases  are  near  of 
kin,  and  that  the  discrimination  is  important  more  as  a  matter  of  ab- 
stract science  than  as  one  of  any  bearing  on  the  therapeutics.  It  is, 
however,  sometimes  a  matter  of  moment  to  distinguish  between  the 
1  "De  la  catalepsie,"  "  Memoires  de  l'Academie  de  M6doeine,"  tome  xx ,  1658,  p.  409. 


CATALEPSY.  749 

cataleptic  paroxysm  and  death.  In  former  times,  instances  <vere  not 
uncommon  in  which  the  mistake  was  made,  to  be  discovered  after  life 
had  really  become  extinct  in  the  coffin.  Such  fatal  errors  would  prob- 
ably be  impossible  now  with  the  stethoscope  for  examining  the  heart, 
the  thermometer  for  determining  the  temperature,  electricity  for  acting 
on  the  muscles,  and,  above  all,  the  ability  to  place  the  limbs  in  posi- 
tions which  they  maintain  against  the  laws  of  gravity.  Moreover,  our 
knowledge  of  diseases  in  general  is  such  as  to  enable  us  to  determine 
with  great  certainty  the  course  they  are  liable  to  take,  and  the  manner 
in  which  death  occurs  in  each. 

Prognosis. — This  is  usually  favorable,  even  in  severe  cases.  All  my 
patients  recovered  under  the  treatment  to  be  presently  mentioned. 

Morbid  Anatomy  and  Pathology. — There  is  not  much  to  say  relative 
to  the  morbid  anatomy  of  catalepsy.  In  some  cases  in  which  death  has 
taken  place,  other  diseases  were  present,  and  the  lesions  found  were 
rather  to  be  associated  with  them  than  with  catalepsy. 

Puel,1  in  his  very  elaborate  treatise,  says  that  the  first  report  of  a 
post-mortem  examination  of  a  patient  dying  while  subject  to  the  dis- 
ease in  question  is  that  of  Hollerius,  made  in  159G.  The  patient,  a 
man,  had  but  one  paroxysm,  and  died  the  same  day.  The  lungs  and 
liver  were  gangrenous,  a  collection  of  reddish  serum  was  found  in  the 
posterior  part  of  the  brain,  and  sanguineous  concretions  (thrombi)  in 
the  superior  longitudinal  sinus. 

Deidier,  in  1811,  reported  the  case  of  an  elderly  man  who  had  but 
one  paroxysm,  lasting  a  day,  and  who  died  eight  days  afterward.  In 
this  instance  there  were  found,  on  each  side  of  the  longitudinal  sinus, 
two  little  glandular  bodies  which  were  described  perfectly,  and  to  which 
the  catalepsy  was  attributed.  These  were  nothingmore  than  the  granu- 
lations of  the  dura  mater,  now  known  as  the  Pacchionian  bodi 

In  a  maniac  who  was  subject  to  catalepsy  and  who  died  at  Charen- 
fcon,  in  1834,  the  report  by  Georget  and  Calmeil  states  that  the  pia 
mater  was  found  thickened  and  injected  ;  the  cortical  substance  of  the 
brain  was  reddened  and  softened,  and  the  white  substance  contained 
enlarged  vessels.  En  another  case  the  same  observers  found  the  cortical 
Bubstance  discolored,  and  the  white  tissue  injected.  As  they  remark, 
however,  these  are  the  lesions  of  insanity  with  general  paralysis 

In   other  .,  alterations  which   could  normally  be  i 

with  the  cataleptic  phenomena  wen- discovered. 

The  pathology  of  catalepsy  is  very  imperfectly  known.  The  symp- 
toms   indicate    thai    the  braill  and  spinal  cord  are  involved,  and  there  ifl 

some  evidence  to  show  that  they  are  in  a  state  of  aneemia.  But  there 
i  condition  induced  in  these  organs  which  is  the  essential  feature  of 
the  disease,  and  of  this  we  know  nothing.  ■  There  is  a  possibility  that 
tiie  affection  may  be  a  masked  form  of  epilepsy,  and  this  view  is  born* 

1  Op.  eit.,  p 


750  CEREBRO-SPINAL   DISEASES. 

out  by  the  fact  that  the  treatment  which  is  most  successful  in  this  lat- 
ter disease  is  most  efficacious  in  catalepsy. 

But  recent  researches  have  served  to  give  us  perhaps  some  inkling 
of  the  real  nature  of  catalepsy,  and  to  supply  us  with  examples  of  arti- 
ficially-induced cataleptiform  phenomena  which  are  of  great  interest  as 
analogical  to  instances  of  the  natural  disease.  The  investigations  which 
have  been  made  relative  to  motor  centres  in  the  brain  lead  us  to  sup- 
pose that  there  are  likewise  inhibitory  centres  in  the  cerebro-spinal  sys- 
tem, probably  both  in  the  brain  and  spinal  cord.  We  often  meet  with 
cases  in  which  there  is  complete  paralysis  of  one  or  more  parts  of  the 
body,  and  which  are  suddenly  caused  by  some  strong  impression  pro- 
duced upon  the  emotions.  Now,  catalepsy  is,  for  the  time  being,  a  pa- 
ralysis of  the  will,  a  condition  in  which,  while  the  muscles  have  not  lest 
their  power  to  contract,  there  is  a  loss  of  volitional  influence  over  them. 
They  are  still  capable  of  responding  to  stimulation  from  without,  but,  in 
the  absence  of  stimulation  from  within,  they  retain  whatever  degree  of 
contraction  may  be  given  to  them. 

Some  of  the  results  which  follow  experiments  made  to  induce  what 
is  called  the  hypnotic  state,  are  very  suggestive  of  catalepsy.  A  era  vv- 
fish,  as  Czermack  '  has  shown,  can  be  thrown  into  the  cataleptic  condi- 
tion, during  which  he  is  rigid  and  immovable.  And  I  have  repeatedly 
put  frogs,  lobsters,  and  hens,  into  a  similar  state.  The  full  considera- 
tion of  these  interesting  phenomena  would  be  out  of  place  in  a  practi- 
cal treatise  on  diseases  of  the  nervous  system.8 

But  I  may  at  least  state  that  I  have  recently  developed  the  most 
intense  cataleptoid  phenomena  in  several  subjects  through  the  influ- 
ence of  suggestion,  while  they  were  in  the  hypnotic,  or,  as  I  think  it 
should  more  properly  be  called,  the  syggignostic  (ovyytyvo)OKcj,  to 
agree  with)  condition.  Among  other  exhibitions  of  the  phenomena  is 
one  which  is  especially  striking.  By  merely  telling  the  subject  that 
his  body  is  so  rigid  that  he  cannot  bend  it,  he  at  once  becomes  cata- 
leptic in  every  voluntary  muscle,  and  may  then  be  laid  upon  the  backs 
of  two  chairs,  as  shown  in  the  cut  (Fig.  106),  in  which  position  he  will 
remain  for  several  minutes  ;  then  the  muscles  gradually  become  unable 
longer  to  endure  the  strain,  and  the  body  sinks  slowly  to  the  floor. 
Very  few  trained  gymnasts  could  perforin  this  feat  at  all,  and  no  one 
in  his  normal  state  could  maintain  the  necessary  muscular  tension  as 
long  as  the  physically  weak  young  man  from  whom  the  drawing  is 
made.  As  is  seen,  the  body  rests  only  on  the  occiput  and  on  one  os 
calcis  ;  and  I  have  known  the  position  to  be  steadily  kept  for  full 
five  minutes.     In  these  cases  there  is  no  excitation  of  muscular  con- 

1  "  On  Hypnotism  in  Animals,"  translated  from  the  German  by  Clara  Hammond, 
Popular  Science  Monthly,  September  and  November,  1873. 

2  For  a  more  complete  account  of  the  phenomena  and  physiology  of  catalepsy,  ecsta- 
sy, somnambulism,  etc.,  the  reader  is  referred  to  the  author's  work  "  On  Certain  Condi- 
tions of  Nervous  Derangement,"  New  York,  G.  P.  Putnam's  Sons,  1881. 


CATALEPSY. 


rsi 


traction  by  reflex  action,  such  as  is  supposed  by  Charcot  and  Hei- 
denhain  to  produce  it,  but  it  is  induced  solely  by  suggesting  to  the 


Fig 


subject  that  his  body  is  in  a  rigid  state.  Immediately  the  muscles 
become  tense,  and  he  can  be  handled  like  a  board. 

There  may  thus  be  in  catalepsy  inhibitory  lesions,  just  as  in  epilepsy 
there  arc  discharging  lesions.  But  as  in  this  latter  disease  there  is 
something  more  than  the  convulsive  movements,  so  in  catalepsy  there 
is  a  morbid  element  in  addition  to  the  muscular  inhibition.  And  this 
appears  to  be  an  overwhelming  inclination  to  agree  with  the  sugges- 
tions received  from  other  persons.  Catalepsy  is  therefore  hypnotism 
— or,  as  I  prefer  to  call  it,  from  its  main  characteristic,  syggignoscisni 
— with  the  addition  of  phenomena  of  muscular  rigidity.  Any  syggi- 
gnostic  subject  can  be  thrown  into  a  cataleptic  condition,  and  the  cata- 
leptic patient  can  readily  be  made  to  exhibit  the  ordinary  manifesta- 
tions of  syggignoscism. 

Treatment. — The  bromide  of  potassium,  or  otic  of  the  other  bro- 
mides previously  mentioned  under  the  head  of  epilepsy,  is  the  mosl 
efficient  agenl  in  the  treatment  of  catalepsy.     I  have  never  yet  failed 

to  <ure  the  disease  with  this  remedy,  combined  with  the  oxide  of  zinc, 
and  with  the  simultaneous   use  of  strychnia    and  other  tonics.      I  have 

never,  however,  had  occasion  to  give  it   in  larger  doses  than  twenty 

grains,  three  times  a  day.  or  to  continue  it  beyond  eight   months. 

In  no  disease  of  the  nervous  system,  not  even  excepting  hysteria,  is 

it  more  necessary  that  the  mind  should  be  brought  under  proper  disci- 
pline, and  kept  as  far  as  possible  from  the  operation  of  all  causes  calcu- 
lated to  promote  emotional  excitement.  At  the  same  time,  a  well- 
regulated  Bystem  of  hygiene,  as  regards  all  the  physical  requirements 
of  the  bodj ,  is  indispi  usable. 


752  CEREBRO- SPINAL   DISEASES. 

n. 

ECSTASY. 

Though  closely  allied  to  'atalepsy,  ecstasy  differs  from  it  in  several 
important  particulars.  One  of  the  main  points  of  difference  is,  that  the 
patient  recollects  the  train  of  thought  which  has  been  going  on  during 
the  seizure,  and  this  of  itself  is  sufficient  to  warrant  their  being  sepa- 
rately considered.  It  often  happens,  however,  that  the  two  diseases 
alternate  or  coexist. 

Symptoms. — In  ecstasy  there  is  muscular  immobility  rather  than 
rigidity,  although  the  latter  is  sometimes  present  ;  the  eyes  are  open, 
the  lips  parted  ;  the  face  is  turned  upward,  the  hands  are  often  out- 
stretched ;  the  body  is  erect  and  raised  to  its  utmost  height,  or  else  is 
extended  at  full  length  in  the  recumbent  posture.  A  peculiar  radiant 
smile  illumes  the  countenance,  and  the  whole  aspect  and  attitude  is  that 
of  intense  mental  exaltation. 

The  mind  is  so  filled  with  some  particular  train  of  thought,  that  ex- 
citations of  the  senses,  if  of  moderate  intensity,  are  not  perceived.  We 
meet  with  this  fact  often  in  normal  conditions,  when  the  mind  is  deeply 
engaged  in  reflection,  or  when  it  is  engrossed  with  some  powerful  emo- 
tion. 

Sometimes  there  is  complete  silence,  the  mind  being  apparently  ab- 
sorbed with  meditation  or  with  the  contemplation  of  some  beatific  vision. 
Again,  there  may  be  mystical  sjDeaking,  prophesying,  singing,  or  the 
lips  may  be  in  motion  as  if  in  speaking,  but  without  any  sound  escap- 
ing. 

At  times  various  attitudes  are  assumed  which  are  in  consonance 
with  the  ideas  passing  through  the  ecstatic's  mind.  Again,  stigmata 
or  spots  of  blood  appear  in  the  hands  or  other  parts  of  the  body,  and 
which  are  supposed  to  represent  the  wounds  made  by  the  nails  in  the 
hands  and  feet  of  Jesus,  or  the  thrust  of  the  spear  in  his  side  ;  and, 
again,  a  real  or  assumed  abstinence  from  food  exists. 

Among  the  ecstatics  of  a  former  period,  St.  Francis  of  Assisi,  St. 
Catherine  of  Sienna,  St.  Theresa,  Joan  of  Arc,  and  Madame  Guyon,  are 
to  be  mentioned,  and  whole  sects,  both  among  Catholics  and  Protes- 
tants, exhibited  all  the  manifestations  of  the  disorder. 

.Must  of  the  religious  impostors  who  have  at  various  times  made 
their  appearance,  and  many  very  sincere  and  devout  persons,  have  been 
ecstatics. 

In  its  combinations  with  catalepsy,  chorea,  and  hysteria,  ecstasy  has 
frequently  played  an  important  part  in  the  history  of  the  civilized  world 
— at  one  time,  leading  to  a  belief  in  witchcraft  ;  at  another,  to  demoni- 
ac and  angelic  possession  ;  at  another,  to  mesmerism  and  clairvoyance; 
and,  in   our   day,  tc    spiritualism.     The  consideration   of  these   follies, 


ECSTASY.  753 

though  interesting,  scarcely   comes  within  the  scope  of  the  present 
treatise. 

But  within  the  last  few  years  several  very  remarkable  examples  of 
ecstasy  have  been  observed,  and  some  references  to  two  or  three  of 
them  will  probably  not  be  out  of  place. 

First  among  them,  as  well  on  account  of  the  interesting  phenom- 
ena manifested  as  from  the  fact  that  the  patient  was  regarded  by  a 
great  many  religious  enthusiasts — physicians  among  them — as  the  sub- 
ject of  miraculous  interference,  must  be  placed  Louise  Lateau.1  With- 
out going  into  the  full  details  of  the  case,  a  short  account  will  probably 
prove  both  interesting  and  instructive  : 

Louise  Lateau  was  born  at  Bois-d'Haine,  a  small  village  in  Belgium, 
on  the  30th  of  January,  1850.  She  was  reared  in  the  utmost  poverty, 
was  chlorotic,  and  did  not  menstruate  till  she  was  eighteen  years  old. 
She  loved  solitude  and  silence,  and  when  not  engaged  in  work — and 
she  does  not  appear  to  have  labored  much — she  spent  her  time  in  medi- 
tation and  prayer.  She  was  subject  to  paroxysms  of  ecstasy,  during 
which,  as  many  other  ecstatics,  she  spoke  very  edifying  things,  of  char- 
ity, poverty,  and  the  priesthood.  She  saw  St.  Ursula,  St.  Roch,  St. 
Theresa,  and  the  Holy  Virgin.  Persons  who  saw  her  in  these  states 
declared  that,  while  lying  on  the  bed,  her  whole  body  was  raised  up 
more  than  a  foot  high,  the  heels  alone  being  in  contact  with  the  bed. 

The  stigmatization  ensued  very  soon  after  these  seizures.  On  a  Fri- 
day she  bled  from  the  left  side  of  her  chest.  On  the  following  Friday 
tli is  flow  was  renewed,  and  in  addition  blood  escaped  from  the  dorsal 
surface  of  both  feet  ;  and  on  the  third  Friday  not  only  did  she  bleed 
from  the  side  and  feet,  but  also  from  the  dorsal  and  palmar  surfaces 
of  both  hands.  Every  succeeding  Friday  the  blood  flowed  from  these 
places,  and  finally  other  points  of  exit  were  established  on  the  forehead 
and  between  the  Bhcralders. 

1  For  the  theological  view  of  this  remarkable  case  the  reader  is  referred  to  the  follow- 
ing  works,  a  pari  onlj  of  those  written  in  support  of  her  pretensions:  "Louise  Lateau  de 
Maine,  sa  vie,  Be  rtee ;  6tude  medicale,"  par  le  Dr.  F.  Lefebvre, 

de  pathologi  '  le  et  de  tWrapeutique  a  la  univereite  catholique  de  Lou- 
rain,  etc,  Louvain,  1878 ;  "  Lea  stigmatiseeB  Louise  Lateau  de  Bois-d'Haine,  scaur  Ber- 
nard de  In  Croix,  etc.,"  par  le  I'r.  A.  tmbert-Gourbeire,  professeur  a  l'lcole  de  medecine 

de  i  I'M a  Ferrand,  Paris,  1^7:;-,  "  Biographic  de  Louise  Lateau, la  stigmatiseedi 

d*Haine,"  par  II.  Van  Looy-Tournai,  Paris  and  Leipzig,  1814  ;  "Louise  Lateau  la  Btigma- 

■  1-  Bois-d'Haine  d'apres  des  Bouroes  authentiquea,  medical  iquea,"  par 

I.  professeur  docteur  A.   Rohling,  translated   from  the  German  by  Dr.  Arsene  de  None, 

Ilea  el    Paris,    L8W;  '  Louise  Lateau,  ihr  Wunderleben  und   ibre    Bedutung   im 

deutsoher  Kirchenconflicte,"  von  Paul  kfajunoke,  Berlin,  1*75. 

An. ..ii'.'  tin-  treatises  in  which  tin'  miracle  is  denied,  and  the  phenomena  attributed  to 
,-iil,. •.  Lateau,  Rapport  medicale  but  la  stigmati 

d'Haine  f.iit  a  ['academic  royale  de  medecine  de  Belgique,"  par  le  Docteur  Warlomont, 

nd  Paii-,  1876;  "Science  et  miracle,  Louise  Lateau,  on  la  stigmatisee  I 
par  I.'   in-.   Bournerille,  Paris,  1876     "Lea  miracles,"  par  If.  Virchow,  Rfvtn  <Ls  cours 
'ifiquet,  January  28,  1875. 


754  CEREBRO-SPINAL  DISEASES. 

At  first  these  bleedings  only  took  place  at  night,  but  after  two  or 
three  months  they  occurred  in  the  daytime,  and  Mere  accompanied  by 
paroxysms  of  ecstasy,  during  which  she  was  insensible  to  all  external 
impressions,  and  acted  the  passion  of  Jesus  and  the  crucifixion. 

M.  "Warlomont,  being  commissioned  by  the  Royal  Academy  of  Medi- 
cine of  Belgium  to  examine  Louise  Lateau,  went  to  her  house,  accom- 
panied by  several  friends,  and  made  a  careful  examination  of  her  per- 
son. At  that  time,  Friday  morning  at  six  o'clock,  the  blood  was  flow- 
ing freely  from  all  the  stigmata.  In  a  few  moments  the  sacrament 
would  be  brought  to  her,  and  then  the  second  act  of  the  drama  would 
begin.  The  scene  that  followed  can  be  best  described  in  M.  Warlo- 
mont's  own  words  : 

"  It  is  a  quarter-past  six.  '  Here  comes  the  communion,'  said  M. 
Niels  [a  priest],  *  kneel  down.'  Louise  fell  on  her  knees  on  the  floor, 
closed  her  eyes  and  crossed  her  hands,  on  which  the  communion-cloth 
was  extended.  A  priest,  followed  by  several  acolytes,  entered  ;  the 
penitent  put  out  her  tongue,  received  the  holy  wafer,  and  then  re- 
mained immovable  in  the  attitude  of  prayer. 

"  We  observed  her  with  more  care  than  seemed  to  have  been  hith- 
erto given  to  her  at  similar  periods.  Some  thought  that  she  was  simply 
in  a  state  of  meditation,  from  which  she  would  emerge  in  the  course  of 
half  an  hour  or  so.  But  it  was  a  mistake.  Having  taken  the  commun- 
ion, the  penitent  went  into  a  special  state.  Her  immobility  was  that 
of  a  statue,  her  eyes  were  closed  ;  on  raising  the  eyelids  the  pupils 
were  seen  to  be  largely  dilated,  immovable,  and  apparently  insensible 
to  light.  Strong  pressure  made  upon  the  parts  in  the  vicinity  of  the 
stigmata  caused  no  sensation  of  pain,  although  a  few  moments  before 
they  were  exquisitely  tender.  Pricking  the  skin  gave  no  evidence  of 
the  slightest  sensibility.  A  limb,  on  being  raised,  offered  no  resistance, 
and  sank  slowly  back  to  its  former  position.  Anfesthesia  was  complete, 
unless  the  cornea  remained  still  impressionable.  The  pulse  had  fallen 
from  120  to  100  pulsations.  At  a  given  moment  I  raised  one  of  the 
eyelids,  and  M.  Verriest  quickly  touched  the  cornea.  Louise  at  once 
seemed  to  recover  herself  from  a  sound  sleep,  arose  and  walked  to  a 
chair,  upon  which  she  seated  herself.  'This  time,'  I  said,  'we  have 
wakened  her.'  '  No,'  said  M.  Niels,  looking  at  his  watch,  '  it  was  time 
for  her  to  awake.'  " 

She  remained  conscious  ;  the  blood  still  continued  to  flow  ;  the  an- 
aesthesia had  ceased,  her  pulse  rose  to  120,  and  at  the  end  of  half  an 
hour  she  was  herself.  "  Our  first  visit  ended  here.  At  half -past  eleven 
we  made  another.  The  poor  child  had  resumed  her  attitude  of  extreme 
suffering,  against  which  she  contended  with  all  the  energy  that  re- 
mained to  her.  The  wounds  in  the  hands  still  continued  to  bleed.  M. 
Verriest  auscultated  with  care  the  lungs,  heart,  and  great  vessels,  and 
found  the  bruit  de  souffle  which  he  had  detected  in  the  morning  at  the 


ECSTASY.  755 

apex  of  the  heart  and  over  the  carotids.  The  handle  of  a  spoon  piessed 
against  the  velum,  the  base  of  the  tongue,  and  the  pharynx,  provoked 
no  effort  at  vomiting.  The  glasses  of  our  spectacles,  as  they  came  in 
contact  with  the  air  expired,  were  covered  with  vapor.  As  the  patient 
appeared  to  suffer  from  our  presence,  we  went  away. 

"  We  made  our  third  visit  at  two  o'clock.  There  were  still  fifteen 
minutes  before  the  beginning  of  the  ecstatic  crisis,  which  always  took 
place  punctually  at  a  quarter-past  two  and  ended  at  about  half-past  four. 
The  pupils  at  this  time  were  slightly  contracted,  the  eyelids  were 
almost  entirely  closed;  the  eyes,  looking  at  nothing,  were  veiled  from 
our  view.  We  tried  in  vain  to  attract  her  attention  ;  her  mind  was 
otherwise  engaged,  and  her  pains  were  evidently  becoming  more  in- 
tense. At  exactly  a  quarter-past  two  her  eyes  became  fixed  in  a  direc- 
tion above  and  to  the  right.     The  ecstasy  had  begun. 

"The  time  had  now  come  to  introduce  those  who  were  prompted  by 
curiosity.  This  could  now  be  done  without  inconvenience,  for  the  ec- 
static, for  the  ensuing  two  hours,  would  be  lost  to  the  appreciation  of 
what  might  be  passing  around  her.  The  room  crowded  could  hold  about 
ten  persons,  but  enough  were  allowed  to  enter  to  make  the  total  twenty- 
five.  These  placed  themselves  in  two  ranks,  of  which  the  front  one 
kneeling  allowed  the  rear  one  to  see  all  that  was  going  on.  All  this 
was  done  under  the  direction  M.  le  Cur§,  who  took  every  pains  to  give 
us  a  good  view  of  Avhat  was  going  to  happen. 

"Louise  was  seated  on  the  edge  of  her  chair;  her  body, inclined 
forward,  seemed  to  wish  to  follow  the  direction  of  her  eyes,  which  did 
not  look,  but  were  fixed  on  vacancy.  Her  eyes  were  opened  to  their 
fullest  extent,  of  a  dull,  lustreless  appearance,  turned  above  and  to  the 
right,  and  of  an  absolute  immobility.  A  few  workings  of  the  lids  were 
now  observed  and  became  more  frequent  if  the  eyelids  were  touched. 
The  pupils,  largely  dilated,  showed  very  little  sensibility  to  light,  and 
all  that  remained  of  vision  was  shown  by  slight  winking  when  the  hand 
was  suddenly  brought  close  to  the  eyes.  The  whole  face  lacked  ex- 
pression. At  certain  moments,  either  spontaneously  or  as  a  conse- 
quence of  divers  provocations,  a  light  smile,  to  which  the  muscles  of  the 
face  generally  did  not  contribute,  wandered  over  her  lips.  Then  the 
face  resumed  its  primitive  expression,  and  thus  she  remained  for  the 
half-hour  which  constituted  the  '  first  station.' 

"The  'second  station'  was  that  of  genuflection.     It  had   failed  at 
one  time,  but  bad  again  appeared.     The  young  girl  fell  on  her  kn 
clasped  her  bands,  and  remained  for  aboul  a  quarter  of  an  hour  in  the 
attitude  of  contemplation.     Then  she  arose  and  again  resumed  her  sit- 
ting  posture. 

"  The  '  third  station '  began  a1  three  o'clock,     Louise  inclined  her* 
s<df  a  little  forward,  raised  her  body  slowly,  and  then  extendi  d  herself 

at  full  length,  face  downward,  on  the  floor.      There  was  neither  rigidity 


756  CEREBRO-SPINAL   DISEASES. 

nor  extreme  precipitation  ;  nothing,  in  fact,  calculated  to  produce  in- 
juries. The  knees  first  supported  her  body,  then  it  rested  on  these  and 
the  elbows,  and  finally  her  face  was  brought  in  actual  close  contact  with 
the  tiled  floor.  At  first  the  head  rested  on  the  left  arm,  but  very  soon 
the  patient  made  a  quick  and  sudden  movement,  and  the  arms  were  ex- 
tended from  the  body  in  the  form  of  a  cross.  At  the  same  time  the  feet 
were  brought  together  so  that  the  dorsum  of  the  right  was  in  contact 
with  the  sole  of  the  left  foot.  This  position  did  not  vary  for  an  hour 
and  a  half.  When  the  end  of  the  crisis  approached  the  arms  were 
brought  close  to  the  sides  of  the  body,  then  suddenly  the  poor  girl  rose 
to  her  knees,  her  face  turns  to  the  wall,  her  cheeks  become  colored, 
her  eyes  have  regained  their  expression,  her  countenance  expands,  and 
the  ecstasy  is  at  an  end." 

Further  particulars  are  given,  and  an  apparatus  was  constructed 
and  applied  to  Louise's  hand  and  arm  so  as  to  prevent  any  external  ex- 
citation of  the  haemorrhage.  It  was  apparently  shown  that  there  was 
no  such  interference,  for  the  blood  began  to  flow  at  the  usual  time  on 
Friday. 

In  addition  to  the  stigmata  and  the  paroxysms  of  ecstasy,  Louise 
declared  that  she  did  not  sleep,  had  eaten  or  drunk  nothing  for  four 
years,  had  had  no  fecal  evacuation  for  three  years  and  a  half,  and  that 
the  urine  was  entirely  suppressed. 

M.  Warlomont  examined  the  blood  and  products  of  respiration 
chemically,  and  satisfied  himself  of  their  normal  character,  except  that 
the  former  contained  an  excessive  amount  of  white  corpuscles. 

When  being  closely  interrogated,  Louise  admitted  that,  though  she 
did  not  sleep,  she  had  short  periods  of  forgetfulness  at  night.  On  M. 
Warlomont  suddenly  opening  a  cupboard  in  her  room,  he  found  it  to 
contain  fruit  and  bread,  and  her  chamber  communicated  directly  with  a 
3rard  at  the  back  of  the  house.  It  was  therefore  perfectly  possible  for 
her  to  have  slept,  eaten,  defecated,  and  urinated,  without  any  one  know- 
ing that  she  did  so. 

The  conclusions  arrived  at  by  M.  Warlomont  were,  that  the  stigma- 
tisations  and  ecstasies  of  Louise  Lateau  were  real  and  to  be  explained 
upon  well-known  physiological  and  pathological  principles,  that  she 
'  worked,  and  dispensed  heat,  that  she  lost  every  Friday  a  certain  quan- 
tity of  blood  by  the  stigmata,  that  the  air  she  expired  contained  the 
vapor  of  water  and  carbonic  acid,  that  her  weight  had  not  materially 
altered  since  she  had  come  under  observation.  She  consumes  carbon 
and  it  is  not  from  her  own  body  that  she  gets  it.  Where  does  she  get 
it  from  ?     Physiology  answers,  '  She  eats.' " 

MM.  Mauriac  and  Verdalle  '  give  a  very  interesting  account  of  an 
ecstatic  woman  who  daily  enacted  the  passion  of  Jesus,  terminating  irj 
the  usual  manner  with  the  representation  of  the  crucifixion.    This  worn- 

1  "  Etude  m6dicale  sur  l'extatique  dc  Fontet,"  Paris,  1875. 


ECSTASY.  757 

an,  Beguille,  was  of  nervous  temperament,  had  had  many  visions  of 
the  Virgin  and  of  angels,  and  was  accustomed  to  prophesy. 

When  visited  by  MM.  Mauriac  and  Verdalle,  Berguille  was  lying  in 
bed.  She  is  described  as  a  woman  of  about  forty-five  years  old,  brown 
complexion,  muscles  and  limbs  well  developed  but  without  much  fat, 
eyes  blue,  widely  open,  and  staring  vaguely.  She  smiled  kindly  when 
questions  were  put  to  her,  and  answered  with  sufficient  intelligence. 

On  being  asked  why  she  was  in  bed,  she  answered  that  she  was  in 
pain  night  and  day  ;  and,  when  requested  to  state  where  she  felt  the 
most  pain,  she  answered,  the  backs  and  palms  of  the  hands,  the  tips 
and  soles  of  the  feet,  and  the  right  side.  (It  will  be  remembered  that 
Louise  Lateau  had  her  pain  and  haemorrhage  in  the  left  side,  a  differ- 
ence which  the  miracle-believers  ought  to  find  it  difficult  to  reconcile.) 

Relative  to  her  visions  and  what  she  heard  during  her  ecstasies,  she 
said  that  she  saw  Jesus  Christ  in  his  passion,  that  she  heard  voices,  but 
she  could  not  repeat  what  was  told  her.     Her  pulse  was  from  68  to  72. 

At  about  one  o'clock  the  ecstasy  began.  Her  pulse  rose  to  80. 
She  clasped  her  hands  on  her  heart,  her  gaze  became  fixed,  her  eyes 
were  widely  opened,  her  lips  moved  as  if  she  were  murmuring  prayers, 
and  there  were  frequent  movements  of  deglutition.  Her  pupils  were 
slightly  dilated,  but  contracted  when  a  light  was  brought  to  them. 
Her  limbs  were  rigid,  but  it  was  noticed  that  she  flexed  them  very  read- 
ily when  she  altered  her  position  a  little  or  arranged  her  dress.  In  a 
few  minutes  she  raised  herself  somewhat  awkwardly  on  her  knees,  her 
hands  still  being  clasped  and  her  eyes  fixed.  Then  began  the  passion  or 
the  way  to  the  cross,  during  which  she  walked  on  her  knees  around  the 
bed,  changing  her  position  twelve  times,  and  falling  three  times  in  the 
traditional  manner.  To  make  this  journey  required  thirty-six  minutes, 
and,  this  done,  the  next  act,  the  crucifixion,  was  in  order. 

Suddenly  she  threw  herself  back  on  the  bed,  extended  her  arms 
from  each  side,  and  remained  immovable.  The  pulse  was  112,  the  res- 
pirations 100.  The  muscles  of  the  chest  seemed  to  be  paralyzed,  only 
the  diaphragm  acting.     The  eyes  were  closed. 

The  limbs  were  in  a  state  of  forced  extension  and  very  rigid  ;  the 
cutaneous  sensibility  to  pinchings,  prickings,  and  to  the  electrical 
stimulus  was  abolished.  The  latter,  a  very  strong  induced  current, 
caused  muscular  contractions  but  no  sensation.  There  was  not  the 
least  flinching.  Things  went  on  in  this  way  for  over  three  hours,  and 
then  sin-  sang  the  Stctive  liegina,  exclaimed  "Oh,  what  sorrow  I"  and 
gradually  recovered  her  senses. 

M.  Bourne vflle1  cites  the  case  of  Ler.,  a  hystero-epileptio,  to  whom 
reference  will  be  again  made,  who  at  one  time  had  a  oruoiform  par- 
oxysm.    Her  head  was  strongly  thrown  back  ;  her  eyelids,  half  open. 

1  "Louidc  Lateau,"  etc.,  Parii,  1S75,  p.  13. 


758 


CEREBRO-SPLYAL   DISEASES. 


ECSTASY.  759 

were  in  continual  motion  ;  the  muscles  of  the  jaws  were  contracted, 
and  the  muscles  of  the  neck  were  hard  and  tense. 

The  superior  extremities  were  extended  at  right  angles  from  the 
trunk,  the  hands  closed,  and  the  fingers  flexed  so  strongly  on  the  palms 
as  to  render  it  impossible  to  open  them. 

The  inferior  extremities  were  stretched  out  to  their  full  length,  the 
sole  of  one  foot  in  contact  with  the  dorsum  of  the  other. 

In  a  word,  the  rigidity  was  such  that  the  body  could  have  been 
raised  from  either  end  like  a  bar  of  iron  (Fig.  107). 

The  attack  lasted  about  four  hours  ;  then  Ler.  opened  her  eyes  and 
recovered  consciousness,  exclaiming,  "  O  my  God,  I  was  so  happy  ! " 

Two  other  interesting  cases  are  described  by  M.  Billet,1  but  the  fore- 
going are  sufficient  to  give  the  reader  some  idea  of  ecstasy  as  it  ap- 
pears in  Catholic  countries. 

But  the  phenomena  exhibited  by  Protestant  ecstatics  have  been 
and  are  to  this  day  fully  as  remarkable  pathologically  as  those  just  de- 
scribed. Calmeil,'  speaking  of  the  Protestant  theomaniacs  of  Langue- 
doc  and  Cevennes,  says  : 

"  In  general,  they  gave  the  name  of  ecstatic  period  to  the  agitation 
and  improvisation  which  characterized  the  attack.  All  the  inspired 
were  fully  persuaded  that  the  Holy  Spirit  had  entered  into  their  breasts 
at  the  moment  when  they  felt  themselves  constrained  by  an  overwhelm- 
ing power  to  prophesy.  All  expressed  themselves  as  if  the  Spirit  of 
God  spoke  to  them  the  words  they  uttered." 

Klizabeth  Barton,  called  the  "Holy  Woman  of  Kent,"  announced, 
during  an  attack  of  hysteria,  that  a  child  then  sick  with  a  brain- 
fever  would  die.  As  she  predicted,  the  event  took  place  soon  after- 
ward, and  the  fulfillment  of  this  prophecy  at  once  gave  the  holy  woman 
a  great  reputation.  On  this  she  announced  that  she  was  illumined  by 
the  Holy  Spirit.  She  had  numerous  ecstatic  paroxysms,  during  which 
she,  according  to  her  own  account,  was  transported  to  heaven,  and  on 
her  emergence  she  sang  hymns,  prayed,  and  made  many  predictions 
which  astonished  her  admirers.  At  last,  in  obedience  to  an  asserted 
command  of  the  Virgin,  she  renounced  Protestantism  and  took  the  veil. 
She  continued  to  prophesy,  and,  growing  bold,  she  predicted  the  speedy 
death  "I  the  king  for  his  putting  aside  his  wife  Catharine  of  Aragon 
for  Anne  Boleyn.  Henry  VIII.  was  not  of  the  temper  to  submit  to 
this  sort  of  holiness,  so  he  had  Elizabeth  Barton  beheaded  as  a  pesti- 
lent woman,  who  was  better  out  of  the  world  than  in  it. 

An  eostatio,  in  a  paroxysm  of  rapture,  having  lost  his  speech,  thus 
lesoribes  his  regaining  the  faculty: 3 

"At    length,  ul'ter    nine,    mouths  of  sobs   and   convulsions    without 

1  "Contributions  ;\  I'dtude  del  QevrosM  extraordinairea,"  Paris,  1874. 
■  "  \><:  la  folie,"  etc,  tome  ii.,  Paris,  1845,  p.  288. 

•  Culnu-il,  »]>.  <it.,  p. 


760  CEREBRO-SPINAL   DISEASES. 

speech,  one  Sunday  morning  as  I  was  praying  in  my  father's  house,  I 
fell  into  an  extraordinary  ecstasy,  and  God  opened  my  mouth.  During 
the  ensuing  three  days  I  was  constantly  under  the  operation  of  the 
Holy  Spirit,  neither  eating,  drinking,  nor  sleeping,  and  I  spoke  often 
with  more  or  less  power,  according  to  the  nature  of  things.  All  in  the 
family  were  convinced,  as  well  by  the  extraordinary  state  in  which  they 
now  saw  me,  as  by  the  wonderful  fasting  of  three  days,  during  which  I 
felt  neither  hunger  nor  thirst,  that  it  was  surely  by  the  Sovereign 
Power  that  such  astonishing  things  were  done." 

In  our  own  day,  instances  of  ecstatic  trance  during  camp-meetings, 
revivals,  and  the  like,  are  common  enough,  and  the  number  is  greatly 
jicreased  by  spiritualism,  mesmerism,  and  such  like  absurdities.1 

As  we  have  seen,  many  ecstatics  pretend  that  they  do  not  eat. 
Cases  of  the  kind  are  reported  very  often,  and  have  been  noticed  from 
an  early  period.  Thus  Schenckius  a  quotes  from  Paulus  Lentulus  tho 
"  Wonderful  History  of  the  Fasting  of  Appolonia  Schreira,  a  Virgin, 
in  Bern,"  in  which  it  is  stated  that,  being  carefully  watched  by  the 
orders  of  the  magistrates  of  Bern,  it  was  ascertained  that  there  was  no 
fraud,  and  she  was  dismissed  as  a  genuine  case  of  ability  to  live  with- 
out food.  During  the  first  year  of  her  fasting  she  scarcely  slept,  and 
in  the  second  year  not  at  all. 

Another,  and  still  earlier  case,  was  that  of  Margaret  "Weiss,  aged  ten 
years,  who  lived  in  Rode,  a  small  village  near  Spires,  and  whose  history 
is  given  by  Gerardus  Bucoldianus.8  Margaret  is  reported  to  have  ab- 
stained from  all  food  and  drink  for  three  years,  in  the  mean  time  grow- 
ing, walking  about,  laughing  and  talking,  like  other  children  of  her  age. 
She,  however,  during  the  first  year  suffered  greatly  from  pains  in  her 
head  and  abdomen,  and,  all  four  of  her  limbs  were  contracted.  She 
passed  neither  urine  nor  faeces.  Margaret  played  her  part  so  well  that, 
after  being  watched  by  the  priest  of  the  parish,  and  Dr.  Bucoldianus, 
she  was  considered  free  from  all  juggling,  and  was  sent  home  to  her 
friends  by  order  of  the  king,  "not  without  great  admiration  and 
princely  gifts."  The  circumstances  seem  to  have  somewhat  stag- 
gered Dr.  Bucoldianus,  for  he  asks,  "  Whence  comes  the  animal  heat, 
since  she  neither  eats  nor  drinks,  and  why  does  the  body  grow  when 
nothing  goes  into  it  ?  " 

Of  the  cases  that  have  been  recently  reported,  that  of  the  so-called 
Welsh  fasting-girl  *  is  one  of  the  most  remarkable,  and  a  few  years  ago 
an  account  of  its  tragical  ending  excited  a  good  deal  of  comment  in  the 

1  For  a  full  discussion  of  this  subject,  tbe  reader  is  referred  to  the  author's  work 
"  On  Certain  Conditions  of  Nervous  Derangement,"  New  York,  1881. 

8  "  HapaTT]iiT]0£uv,  sive  observationum  medicarum,  rararum,  novarum,  admirabilium  et 
monstrosarum  volumen,  toinis  septeui  de  toto  homine  institutum,"  Lugduni,  160G,  p.  306. 

3  "  De  Puella  quaj  sine  eibo  et  potu  vitam  transigit,"  Parisiis,  ann.  MDXLII. 

4  "A  Complete  History  of  the  Welsh  Fasting  Girl,  with  Comments  thereon,  and  Obser- 
vations on  Death  from  Starvation,"  by  Robert  Fowler,  Loudon,  1871. 


ECSTASY.  761 

medical  journals  of  Great  Britain.  Like  the  others,  this  was  a  case  of 
hysteroid  disease,  and  when  she  was  so  strictly  watched  that  deception 
was  no  longer  possible,  she  died  in  a  few  days  of  starvation.  The 
startling  heading:  to  an  editorial  notice  in  the  Lancet  * — "  Starved  to 
Death" — expressed  no  more  than  the  actual  truth. 

In  regard  to  the  rarity  of  defecation  and  urination  in  cases  of  hys- 
teroid disease  there  is  no  doubt.  Such  cases  are  often  accompanied 
with  vomiting,  and  then  the  matter  ejected  from  the  stomach  contains 
urea  and  sometimes  even  fecal  matter.  A  lady,  not  long  since  under 
my  charge,  in  whom  there  were  no  other  very  decided  hysterical  symp- 
toms, had  an  operation  from  her  bowels  never  more  frequently  than 
once  a  month,  and  generally  not  so  often.  Every  time  she  ate  any- 
thing she  vomited  soon  afterward,  and  the  vomited  matter  always  con- 
tained urea.  She  urinated  about  a  tablespoonful  every  eight  or  ten 
days.  The  vomiting  of  fecal  matter  in  cases  of  hysteroid  disease  is  not 
so  common.  Briquet s  reports  a  case  as  occurring  in  his  own  experi- 
ence, in  which  there  was  no  doubt  that  substances  administered  as 
enemas  were  vomited  a  few  minutes  afterward.  Among  other  experi- 
ments, and  in  order  to  remove  all  doubt  arising  from  the  use  of  house- 
hold substances,  an  injection  of  tincture  of  litmus  was  given  immedi- 
ately after  it  was  brought  from  the  pharmacy.  The  patient  was  told 
that  coffee  was  to  be  injected.  Twelve  minutes  afterward  the  tincture 
of  litmus  was  vomited,  its  blue  color  turned  to  a  red  through  the  action 
of  the  gastric  juice. 

Less  authentic,  perhaps,  is  the  following  from  Henricus  ab  Heeres:  ' 

"  A  certain  gentleman  has  lived  several  years  without  having  had 
any  operation  from  his  bowels.  About  the  middle  of  the  day  he  sits 
down  to  his  dinner,  usually  inviting  several  noble  persons  to  eat  with 
him.  In  an  hour  he  rises  from  the  table,  after  having  eaten  and  drunk 
to  his  satisfaction,  and  retiring,  vomits  the  dinner  he  had  eaten  the  day 
before,  hut  retaining  all  the  dinner  he  has  just  taken.  It  is  ejected 
putrid  and  filthy,  differing  in  no  respect  from  other  excrement.  He 
vomits  with  ease,  and  at  once,  throwing  up  the  contents  of  the  stomach 
which  have  remained  from  the  previous  day.  Then  he  washes  his 
mouth  with  clean  water  and  returns  to  his  friends  to  finish  his  repast. 
He  eata  no  supper  or  breakfast,  and  thus  he  has  done  for  about  twenty 
years." 

Stigmata,  as  occasional  symptoms  of  the  hysteroid  condition,  are 
well  known  to  dermatologists,  many  cases  of  bloody  sweat  having  been 
no!  Leed.  Those  observed  in  the  case  of  Louise  Lateau  were  well  b(  udied 
by  M.  Worlomont,  and  they  were  found  to  differ  in  do  essential  respect 
from  those  previously  observed,  except  in  regard  to  the  periodicity  of 

1  jAitirrf,  Deoember  25,  1889. 

8  "Tniitu  oliniqiu  h  tfaSrapentlqae  de  I'hysterie,"  Paris,  1859,  p.  316. 

■  u  ObserrationM  medics,"  Lipsia,  1845,  lib.  I,  ob.  29. 


762  CEREBRO-SPIXAL   DISEASES. 

the  haemorrhages — a  circumstance,  however,  easily  accounted  for  by 
the  fact  that  the  stages  of  excitement  were  regular.  Hoemidosis,  or 
bloody  sweat,  is  to  be  regarded  as  one  of  the  neuroses  of  the  skin.  An 
interesting  case  is  reported  by  Wilson.1  Mason  Good  cites  authorities  to 
show  that  it  has  taken  place  during  coition,  violent  terror,  and  great 
bodily  agony.  Its  occurrence  in  the  hands,  feet,  and  side,  is  to  be  ex- 
plained by  the  fact  that  the  attention  is  strongly  concentrated  on  these 
parts,  and  it  is  in  all  probability  kept  in  these  situations  by  manual 
irritation.  It  is  by  no  means  certain  that  this  latter  was  not  the  case 
with  Louise  Lateau,  for  M.  Warlomont's  apparatus  was  not  of  such  a 
character  as  to  prevent  such  action. 

Causes. — Ecstasy,  though  not  entirely"  confined  to  the  female  sex,  ia 
very  much  more  common  in  women  than  in  men.  It  appears  to  be 
produced  in  those  who  are  of  delicate  and  sensitive  nervous  organiza- 
tions by  intense  mental  concentration  on  some  one  particular  subject — 
generally,  one  connected  with  religion,  or  some  other  abstract  train  of 
thought.  It  was  formerly  quite  common  among  the  inmates  of  con- 
vents, and  is  now  not  unfrequently  met  with  at  camp-meetings  and 
spiritualistic  gatherings. 

There  are  no  points  about  the  Diagnosis  requiring  special  considera- 
tion, and  the  Prognosis  is  always  favorable,  if  the  subject  can  be  sub- 
mitted to  proper  moral  and  physical  treatment.  As  the  disease  is 
never  fatal  per  se,  we  know  nothing  of  its  Morbid  Anatomy.  The 
pathology,  as  indicated  by  the  symptoms,  points  to  the  implication  of 
both  the  brain  and  spinal  cord,  but  there  is  no  satisfactory  theory  of 
the  disorder  other  than  that  which  refers  it  to  cerebral  and  spinal  pre- 
occupation— a  kind  of  setting  of  the  current  in  one  direction,  whereby 
all  other  occupation  is  for  the  time  prevented. 

Treatment. — The  means  of  treatment,  though  not  differing  essen- 
tially from  those  proper  for  catalepsy,  require,  nevertheless,  special 
mention  of  some  particulars.  The  influence  of  moral  force  in  prevent- 
ing and  curing  ecstasy  is  well  marked,  and  many  instances  are  on  record 
in  which  epidemics  of  it  have  been  arrested  by  arguments  addressed  to 
the  fears  of  the  subjects.  I  have  several  times  aborted  and  prevented 
ecstatic  manifestations  by  making  preparations  to  cauterize  the  region 
of  the  spine  with  a  red-hot  iron. 

A  great  deal  can  be  done  by  giving  as  little  notoriety  to  ecstatics 
as  possible.  They  glory  in  the  idea  that  they  are  of  sufficient  impor- 
tance to  excite  attention  and  discussion,  and  they  are  accordingly 
stimulated  to  continue  their  performances  so  long  as  they  are  noticed 
and  an  air  of  mystery  is  attached  to  them. 

Removal  from  all  associations  calculated  to  continue  the  exciting 
and  morbid  train  of  thought  which  has  developed  the  disease  under 
notice,  should,  of  course,  be  a  point  in  the  treatment. 

1  "  On  Diseases  of  the  Skin,"  American  edition,  Philadelphia   1863,  p.  551. 


HYSTERO-EPILEPSY.  763 

Electricity,  and  the  other  measures  of  treatment  recommended  foi 
catalepsy,  will  prove  serviceable  in  ecstasy.  By  galvanization  of  the 
sympathetic  nerve,  I,  on  one  occasion,  immediately  cut  short  a  parox- 
ysm of  ecstasy,  and,  by  continuing  the  practice  every  alternate  day  for 
about  six  weeks,  effectually  cured  the  patient,  who  for  several  years 
had  been  subject  to  seizures  every  two  or  three  days. 

As  means  for  improving  the  general  health  are  almost  invariably 
required,  iron,  quinine,  and  strychnia,  in  the  combination  recommended 
on  page  54,  may  be  administered  with  advantage.  I  have  great  confi- 
dence in  the  bromides,  and  the  patient  should  be  to  a  moderate  extent 
brought  as  soon  as  possible  under  the  influence  of  some  one  of  those 
previously  mentioned. 

III. 

HYSTERO-EPILEPSY. 

The  combination  of  hysteria  with  epilepsy  has  long  been  recognized 
as  existing  and  as  giving  rise  to  one  of  the  most  frightful  affections  to 
be  found  in  the  whole  range  of  neurological  medicine.  In  the  present 
state  of  our  knowledge  it  would,  perhaps,  be  going  too  far  were  we  to 
pronounce  positively  in  favor  of  its  being  a  distinct  pathological  entity 
with  a  different  anatomical  substratum  from  either  hysteria  or  epilepsy, 
and  yet  the  phenomena  are  so  distinct  that  we  certainly  are  warranted 
in  considering  it  separately  from  either  of  these  diseases. 

Symptoms. — An  attack  of  hystero-epilepsy  is  characterized  by  the 
occurrence  of  convulsions  more  or  less  resembling  those  of  epilepsy. 
There  is  usually  in  the  first  place  a  well-marked  tetaniform  spasm, 
though,  sometimes,  this  is  not  very  decided,  and  occasionally  is  not 
observed  at  all.  Then  follow  clonic  convulsions,  during  which  the 
patient  froths  at  the  mouth  and  may  pass  the  urine  or  bite  the  tongue, 
though  these  phenomena,  especially  the  latter,  are  rare.  Loss  of  con- 
sciousness exists  during  this  stage. 

Next  ensues  a  remarkable  series  of  movements,  at  the  beginning  of 
which,  or  during  their  continuance,  the  patient  recovers  consciousness 
to  such  an  extent  as  to  answer  questions,  although  there  is  no  after- 
recollection  of  the  incidents  that  may  have  occurred.  These  move- 
ments are  apparently  voluntary,  and  consist  of  the  most  extraordinary 
contortions  of  the  muscles  of  the  face,  neck,  trunk,  and  extremities,  so 
that  superstitious  people  might  well  imagine  the  existence  of  an  inter- 
nal or  external  diabolical  agency.     During  the  continuance  of  this  part 

of  the  paroxysm  the  patient  tears  with  the  hands  and  teeth  any  thing 
tearable   thai    COmee   within   reach,   and   continually  utters   inarticulate 

sounds  or  words  apparently  in  relation  with  the  ideas  passing  through 
the  mind.  Finally,  the  purely  hysterica]  element  ceases  to  predomi- 
nate, and  the  patient  alternately  weeps  and  laughs,  and  gradually  ac- 
quires a  knowledge  of   what,  is  passing  around. 


1 64 


CEREBRO-SPIXAL   DISEASES. 


During  the  whole  of  the  paroxysm  the  face  is  flushed,  the  pupils  are 
moderately  contracted,  the  pulse  is  accelerated,  the  perspiration  is  in- 
creased in  quantity,  and  the  respiration  is  hurried  and  irregular. 

But  there  are  numerous  deviations  from  this  type  of  a  seizure. 
Sometimes  the  tetanic  spasm  is  wanting,  and  again  it,  or  some  modifi- 
cation of  it,  may  constitute  the  most  marked  part  of  the  convulsive 
period.  Thus  in  a  lady,  who  was  lately  under  my  charge,  the  paroxysm 
began  with  an  opisthotonos,  which  was  immediately  relaxed,  and  again 
renewed,  to  be  again  relaxed,  and  so  on,  for  over  half  an  hour. 

In  a  woman  whom  I  saw  in  the  Pennsylvania  Hospital  several  years 
ago,  in  the  service  of  Dr.  Pepper,  the  convulsions  consisted  of  a  series 
of  rapid  movements  produced,  as  the  patient  lay  on  her  bed,  by  the 
bending  back  of  the  body,  so  as  to  throw  it  into  an  opisthotonotic  posi- 
tion, the  head  and  heels  alone  touching  the  bed,  and  then,  the  muscles 
being  suddenly  relaxed,  allowing  the  buttocks  to  fall  with  force  on  the 
bed.  These  actions  were  continued  with  great  rapidity,  and  without 
intermission  for  an  hour  or  more,  and  were  succeeded  by  a  period  dur- 
ing which  there  were  alternate  laughing  and  weeping. 

Such  cases  are  what  Sauvages  designated  as  hysteria  llbidlnosa. 

But,  in  a  case  now  under  my  care,  the  patient,  a  woman,  has  daily 
attacks  at  about  the  same  hour — three  o'clock  r.  M. — which  are  more  dis- 
tinctly tetaniform  in  the  beginning  than  any  that  have  come  under  my 
observation.  They  consist  of  a  series  of  opisthotonotic  spasms,  during 
which  the  body  is  extremely  rigid.  The  convulsion  is,  however,  unlike 
the  others  referred  to,  very  slowly  developed.  The  body  extended  at 
full  length  in  the  recumbent  posture  gradually  becomes  rigid,  the  legs 
are  slightly  abducted,  the  arms  are  pressed  strongly  against  the  sides, 

Fig.  108. 


the  jaws  are  tightly  closed,  and  the  gaze  fixed  (Fig.  108).  Respiration 
is  entirely  suspended,  and  the  heart  beats  rapidly,  sometimes  as  fre- 
quently as  one  hundred  and  sixty  per  minute.  Then  the  body  is  slowly 
bowed,  so  that  the  head  and  heels  alone  touch  the  bed,  and  is  so  rigid 
and  strongly  arched  that  no  ordinary  force,  such  as  a  powerful  man 
can  exert,  suffices  to  overcome  the  tonicity  of  the  muscles.  In  about  a 
minute  from  the  beginning  of  the  rigidity,  the  spasm  suddenly  relaxes, 
and  with  a  long-drawn  inspiration  the  paroxysm  ends — to  be  again  re- 


HYSTERO-EPILEPSY. 


765 


sumed  in  a  few  minutes  with  a  like  sequence.  In  the  accompanying 
woodcut  (Fig.  109)  is  an  exact  representation  of  this  patient  when  the 
tetanic  spasm  is  at  its  height. 


Fig.  109. 


In  this  case  there  is  a  distinct  aura  starting  from  the  left  ovary,  and 
strong  pressure  exerted  upon  this  organ  suffices  generally,  though  not 
always,  to  cut  short  the  series  of  paroxysms. 

Under  the  name  of  demonomania  many  cases  of  hystero-epilepsy 
have  been  described,  and  the  disease,  like  chorea,  has  at  times  prevailed 
epidemically.  At  Loudun,  in  France,  it  led  to  the  death  at  the  stake 
of  Urbain  Grandier,  the  nuns,  who  were  its  subjects,  accusing  him  in 
their  delirium  of  having  bewitched  them.  At  Marseilles,  Father  Louis 
Gaufridi,  a  man  of  education  and  of  strict  morality,  was  accused  by  two 
line  nuns  of  having  debauched  them  through  diabolical  agency. 
At  the  time  of  the  accusation,  these  nuns,  one  of  them  only  nineteen 
old,  were  suffering  from  attacks  characterized  by  hallucinations 
and  illusions,  fearful  epileptiform  and  cataleptiform  convulsions,  and 
delirious  ravings  —all  of  which  were  ascribed  to  the  devil  moved  and  in- 
stigated by  Louis  Gaufridi  At  fust,  the  accused  denied  the  charges 
made  against  him,  and  endeavored  by  arguments  to  show  the  teal 
nature  of  the  seizures.  But  the  effort  was  in  vain,  just  as  is  the  at- 
tempt now  to  convince  the  credulous  and  ignorant  of  the  real  nature 
of  the  seizures  of  Louise  Lateau,  Bernadette  Soubirous — who  evoked 
Our  Lady  of  Lourdes — and  of  the  hundreds  of  mediums,  ecstatics,  and 

hysterics,  who  pervade  the  world.     Gaufridi  became  insane,  and  < - 

fessed  all  that  was  laid  to  his  charge,  with  numerous  other  offei 

which  had  i.ot  been  imagi 1.     Be  declared  that  he  had  worshiped  tin 

de\  il  lor  fourteen  years;  that  the  demon  had  given  him  power  to  render 
amorous  of  his  person  ,-dl  women  on  whom  he  should  breathe,  and  that 
he  had  thus  ovei me  s.\  era!  thousand  women!    ( raufridi,  after  horrible 

tortures,  was  burned  at    tin'  stake;    and  the  two  nuns    u  c..nt  inued  t 
delirious, "  as  well  they  might. 

bowing  the  nature  <>f  the  phenomena  exhibited  in  cases  of  de- 


766  CEREBRO-SPIXAL   DISEASES. 

moniacal  possession  and  their  resemblance  to  the  symptoms  of  hystero- 
epilepsy  and  other  forms  of  hysteria,  I  subjoin  the  following  questions 
as  proposed  by  Santerre,  priest  and  promoter  of  the  diocese  of  Nimes, 
to  the  University  of  Montpellier  : 

Question  1.  Whether  the  bending,  moving,  and  removing  of  the 
body,  the  head  touching  sometimes  the  soles  of  the  feet  (opisthotonos), 
and  other  contortions  and  strange  postures,  are  a  good  sign  of  posses- 
sion? 

2.  "Whether  the  quickness  of  the  motion  of  the  head  forward  and 
backward,  bringing  it  to  the  back  and  breast,  be  an  infallible  mark  of 
possession  ? 

3.  Whether  a  sudden  swelling  of  the  tongue,  the  throat,  and  the 
face,  and  the  sudden  alteration  of  the  color,  are  certain  marks  of  pos- 
session ? 

4.  Whether  dullness  and  senselessness  or  the  privation  of  sense,  even 
to  be  pinched  and  pricked  without  complaining,  without  stirring,  and 
even  without  changing  color,  are  certain  marks  of  possession  ? 

5.  Whether  the  immobility  of  all  the  body,  which  happens  to  the 
pretended  possessed  by  the  command  of  their  exorcists,  during  and  in 
the  middle  of  the  strongest  agitations,  is  a  certain  sign  of  a  truly  dia- 
bolical possession  ? 

6.  Whether  the  yelping  or  barking  like  that  of  a  dog,  in  the  breast 
rather  than  in  the  throat,  is  a  mark  of  possession  ? 

7.  Whether  a  fixed,  steady  look  upon  some  object,  without  moving 
the  eye  on  either  side,  be  a  good  mark  of  possession  ? 

8.  Whether  the  answers  that  the  pretended  possessed  make  in 
French  to  some  questions  that  are  put  to  them  in  Latin  are  a  good 
mark  of  possession. 

9.  Whether  to  vomit  such  things  as  people  have  swallowed  be  a  sign 
of  possession  ? 

10.  Whether  the  prickings  of  a  lancet  upon  divers  parts  of  the  body 
without  blood  issuing  therefrom  are  a  certain  mark  of  possession  ? 

All  these  questions,  to  the  credit  of  medical  science — which  has 
always,  notwithstanding  the  weakness  of  some  of  its  professors  even  in 
our  own  day,  been  steadily  opposed  to  supernaturalism — were  answered 
in  the  negative.  No  one  can  read  them  without  being  struck  with  the 
facts  that  Father  Santerre  was  at  least  a  good  symptomatologist,  and 
of  the  absolute  identity  of  the  phenomena  cited,  in  all  essential  char- 
acteristics, with  those  which  in  our  day  are  said  to  be  of  mystical  origin, 
but  which  in  reality  are  hysterical  or  hysteroid.  We  might  reproach 
Father  Santerre  and  his  coadjutors  more  forcibly,  if  we  had  not  our- 
selves killed  witches  and  presided  at  the  birth  of  spiritualism. 

No  one  has  written  with  greater  effect  in  regard  to  the  manifesta- 
tions of  hysteria  and  hystero-epilepsy  than  Charcot.     As  a  most  strik 


HYSTERO-EPILErSY. 


r67 


ing  case  of  the  latter  affection,  I  cite  from  him  the  following  instance ' 
already  referred  to  in  another  connection  under  the  head  of  ecstasy. 

Ler.,  aged  forty-eight  years,  is  a  patient  well  known  to  all  physi- 
cians who  visit  the  Salpetriere  as  one  of  the  most  remarkable  instances 
extant  of  hystero-epilepsy.  Her  menstruation  has  ceased  for  four 
years  and  yet  all  the  neurotic  symptoms  persist.     She  is  a  demoniac,  a 

Fi<;.  110. 


possessed,  and  presents  a  striking  example  of  thai  type  of  hysteria 
manifested  by  the  "Jerkers"  in  "Methodisl  camp-meetings,"  and  wrho 
exhibit  in  their  paroxysms  the  most  frightful  attitudes. 

The  probable  origin  of  these  nervous  phenomena  in  Ler.  deserves  to 
be  noted.  She  has  bad,  as  >lie  Bays,  a  Beries  of  frights.  At  eleven 
ream  of  age  she  was  terrified  by  u  furious  dog.     At   .sixteen  she  was 

1  "I,. •run-,  >ar  lesmakdUt  du  -  a  la  Salpetriare,"  Paria,  187S 

p.  801,  <i  ■••"/. 


res 


CEREBRO-SPIXAL   DISEASES. 


frightened  at  the  sight  of  the  corpse  of  an  assassinated  woman,  and 
again  about  the  same  time,  when  going  through  a  wood,  by  robbers  who 
attacked  her  and  took  her  money. 

With  her  there  are  local  hysterical  manifestations  consisting  of 
hemi-aiuesthesia,  ovarian  tenderness,  paresis,  and  at  times  contraction 
of  the  limbs  on  the  right  side.  Sometimes  these  symptoms  are  shown 
on  the  left  side  also. 

The  attacks,  which  are  announced  by  a  well-marked  ovarian  aura, 
are  characterized  at  first  by  epileptiform  and  tetaniform  convulsions  ; 


Fig.  111. 


after  which  come  extensive  movements  of  an  intentional  character,  in 
which  the  patient  assumes  the  most  hideous  postures,  recalling  the 
attitudes  which  history  ascribes  to  demoniacal  possession  (Figs.  110  and 
111).  At  the  moment  of  the  attack  she  is  seized  with  delirium,  which 
evidently  turns  on  the  events  which  have  produced  the  initial  seizures. 


HYSTERO-EPILEPSY. 


769 


She  hurls  invectives  at  imaginary  persons.  "  Scoundrels  !  robbers!  brig- 
ands.    Fire,  fire  !  Oh,  the  dogs,  they  bite  me  !  " 

When  the  convulsive  part  of  the  accession  is  over,  there  ensue,  gen- 
erally, hallucinations  of  sight — she  sees  frightful  animals,  skeletons, 
and  spectres  ;  a  paralysis  of  the  bladder  ;  a  paralysis  of  the  pharynx; 
and  a  contraction,  more  or  less  permanent,  of  the  tongue. 

It  is  therefore  necessary  for  several  days  to  feed  her  through  a  tube, 
and  to  empty  the  bladder  with  a  catheter. 

Later,  M.  Bourneville  '  has  given  an  account  of  Ler.,  somewhat 
fuller  than  that  of  M.  Charcot,  to  which,  as  showing  how  Ler.  had  at 
one  time  exhibited  phenomena  of  ecstasy  similar  to  those  present  in 
I.<mise  Lateau,  reference  has  already  been  made.  In  further  illustra- 
t  ion  of  the  period  of  contortions  in  her  case  I  take  from  M.  Bourneville's 
excellent  monograph  the  accompanying  woodcut  (Fig.  112),  made  from 
a  sketch  taken  on  the  spot  by  M.  Charcot. 

Fig.  112. 


In  tlir  intervals  between  the  paroxysms  the  subjects  of  hystero-epi- 
I  generally  exhibil  some  of  the  phenomena  of  hysteria  Buoh  as  hemi- 
anaesthetic  contractions,  ovarian  tenderness,  paralyses,  i  to. 

Relative  to  the  Causes,  the  Prognosis,  Diagnosis,  Morbid  Anatomy 
and  Pathology,  :md  Treatment,  there  is  nothing  to  add  to  the  remarks 

already  made    when    hysteria,   catalepsy,  and    ecstasy,  wire    under   OOn- 
si  fiat  ion. 

1  u Louise  Lateau, on  la  itigmausee  beige,"  Paris,  Is7">,  p.  88,  rittq 

no 


770  CEREBRO-SPIXAL   DISEASES. 

CHAPTER  VII. 

MULTIPLE   CEREBRO-SPIXAL   SCLEROSIS. 

We  have  already  considered  the  subject  of  sclerosis  as  it  affects  the 
brain  and  spinal  cord  separately.  We  have  still  to  treat  of  it  as  exist- 
ing in  these  nervous  centres  simultaneously.  Although  recognized, 
over  thirty-five  years  ago,  by  Cruveilhier  and  Carswell,  it  is  only  re- 
cently, mainly  through  the  observations  of  Charcot  and  Vulpian,  that 
attention  has  been  again  directed  to  sclerosis  of  the  cerebro-spinal 
variety,  a  form  which  differs  from  those  already  described  in  this 
treatise,  both  in  its  extent  and  in  the  symptoms  by  which  it  is  charac- 
terized. 

Symptoms. — The  initial  symptoms  vary  according  as  the  morbid 
process  begins  in  the  brain  or  spinal  cord.  In  the  former  case,  the  first 
prominent  manifestation  of  disease  may  be  an  epileptic  fit.  In  other 
cases,  there  are  headache,  vertigo,  ocular  troubles,  such  as  ptosis,  diplo- 
pia, or  amblyopia,  failure  of  the  hearing,  and,  very  often,  defective 
articulation.  The  mind  does  not  participate  to  any  considerable  extent, 
unless  the  hemispheres  be  involved  in  the  lesion. 

Or,  there  may  be  hemiplegia  as  a  consequence  of  cerebral  conges- 
tion, and  even  mania,  from  a  like  cause.  These  attacks  are  sometimes 
frequent,  and  usually  leave  more  or  less  mental  weakness  after  them. 

Tremor  is  often  first  seen  in  the  tongue,  more  frequently  in  the  eye- 
ball, of  ent,  or  both  sides,  which  oscillates  when  the  patient  is  told  to 
turn  it  inward  >^r  outward,  but  which  is  steady  when  he  looks  directly 
to  the  front.  This  tremor  is  called  nystagmus,  and  is,  as  we  have 
already  seen,  liivt  with  in  other  diseases  of  the  nervous  system.  Ac- 
cording to  Feiner's '  observations,  it  is  due  to  lesion  of  the  cerebel- 
lum, and  when  met  with  in  the  disease  under  notice  points  to  this  organ 
as  one  of  the  seats  of  the  morbid  process.  In  the  case  of  a  woman  who 
attended  my  clinic  at  the  Bellevue  Hospital  Medical  College,  nystag- 
mus was  the  only  symptom  observed  for  over  a  year,  and  then  gradu- 
ally other  phenomena  of  the  cerebro-spinal  form  of  sclerosis  made  their 
appearance. 

Tremor  is  indicative  of  loss  of  power,  and  it  gradually  becomes  more 
strongly  marked  and  extends  to  other  muscles  of  the  body  as  other 
carts  of  the  eerebro-spinal  system  become  involved.  It  is  never,  how- 
ever, a  constant  phenomenon  in  any  form  of  sclerosis  affecting  the 
spinal  cord  alone.  Its  presence  is  peculiar  either  to  cerebral  disease  or 
to  lesions  occurring  in  the  pons  or  in  the  medulla. 

After  a  time,  which  is  subject  to  great  variation  in  different  cases, 

1  "Experimental  Researches  in  Cerebral  Physiology  and  Pathology,"  "  Wctit  Riding 
Lunatic  Asylum  Medical  Reports,"  vol.  iii.,  1873,  p.  69. 


MULTIPLE    CEREBRO-SPINAL  SCLEROSIS.  771 

the  loss  of  power  extends  to  the  limbs,  and  this  feature  is  often 
accompanied  with  aberrations  of  sensibility.  If,  as  is  generally 
the  case,  the  membranes  of  the  cord  are  congested  or  inflamed, 
there  are  spasmodic  jerkings  or  twitehings  of  the  limbs,  but  in  some 
cases  these  are  never  observed.  In  the  case  of  a  gentleman  from 
South  Carolina,  who  consulted  me  at  the  instance  of  my  friend 
and  colleague  Prof.  J.  T.  Darby,  and  who  was  obviously  affected 
with  multiple  cerebro-spinal  sclerosis,  there  had  never  been  the 
slightest  involuntary  movement,  independent  of  the  peculiar  form 
of  tremor  in  the  limbs  which  constitutes  so  prominent  a  feature  of 
the  disease. 

The  lower  extremities  are  generally  very  much  more  paralyzed 
than  the  upper,  and,  when  they  become  involved,  festination  often 
makes  its  appearance.  The  gait  of  the  patient  thus  becomes  similar 
to  that  of  a  person  suffering  from  paralysis  agitans. 

If  the  sclerosis  begins  in  the  brain  before  attacking  the  spinal 
cord,  tremor  precedes  the  paralysis — the  affection  being  then  en- 
tirely cerebral  in  character  ;  but  when,  as  is  generally  the  case,  the 
lesion  appears  primarily  in  the  spinal  cord,  paralysis  is  noticed  be- 
fore the  tremor.  In  fact,  there  is  never,  as  previously  insisted  on 
in  my  remarks  on  paralysis  agitans,  any  tremor,  unless  the  superior 
ganglia  of  the  cerebro-spinal  system  are  involved.  The  fact  that  it 
is  only  shown  when  a  voluntary  movement  is  made  also  assists  us 
to  distinguish  it  from  the  tremor  of  paralysis  agitans,  as  well  as  from 
other  forms  of  tremor.  In  the  cerebro-spinal  form  of  the  disease, 
therefore,  the  patient  remains  without  tremor  so  long  as  he  is  qui- 
escent. But  if  he  attempts  to  cross  one  leg  over  the  other,  or  to 
carry  a  glass  of  wafer  to  his  lips,  the  extremity  executing  the  move- 
ment is  at  once  seized  with  tremor,  and  the  act  is  performed  with 
greal  difficulty. 

The  ability  to  place  the  fingers  on  any  part  of  the  body,  unassisted 
by  the  eyesight,  is  impaired,  as  in  paralysis  agitans,  and  in  sclerosis 
affecting  the  posterior  columns  of  the  spinal  cord. 

As  the  disease  advances,  symptoms  indicative  of  lesions  of  the 
cord  appear.  These  symptoms  seldom  point  to  disease  of  symmet- 
rical tracts.  Thus,  in  one  leg,  the  symptoms  observed  may  he  those 
of  inflammation  of  the  lateral  pyramidal  tract — that  is,  slight  paresis, 
stiffness  and  rigidity  of  the  muscles,  exaggerated  knee-jerk,  and  the 

ankle  clonus,  while  the   other  leg   may  evince   no   abnormal    symptoms 

whatever,  or  else  may  show  evidence  of  disease  of  the  posterior  col- 
umns of  the  same  side  by  the  presence  of  pain,  anaesthesia,  Io-n  of  the 
knee-jerk,  loss  of  the  muscular  sense,  tactile  sense,  and  temperature 
sense.  The  arms  may  show  the  same  divergence  of  symptoms.  There 
may  also  be  paralysis  of  the  bladder,  constipation,  and  a  tendency  t< 

t  he  format  ion  of  lied 


772  CEREBRO-SPINAL  DISEASES. 

Thus,  it  is  evident  that,  in  the  affection  under  consideration,  we 
are  not  confronted,  as  a  rule,  with  lesions  confined  to  one  or  more  of 
the  "  system  tracts."  On  the  contrary,  it  is  quite  apparent  that  the 
diseased  areas  are  scattered  about  in  patches  or  islets,  at  one  level 
affecting  one  tract,  at  another  level  another  tract,  while  at  many  other 
levels  the  entire  segment  of  the  cord  may  be  normal.  The  head  symp- 
toms likewise  increase  in  intensity,  but  the  mind  remains  clear  to  the 
last  in  the  great  majority  of  cases.  Indeed,  my  observation  of  many 
cases  has  convinced  me  that  in  the  cerebro-spinal  form  of  sclerosis  the 
hemispheres  are  not  often  involved,  even  when  the  disease  has  lasted 
several  years. 

The  difficulties  of  articulation  notably  increase,  and  the  muscles  of 
deglutition  likewise  become  involved.  In  consequence,  the  saliva  is 
not  swallowed  as  often  as  it  should  be,  and  it  therefore  dribbles  from 
the  mouth.  Mastication  is  difficult,  and  the  facial  muscles  gradually 
become  involved.  The  countenance  of  the  patient  at  this  period  is 
not  unlike  that  of  a  person  suffering  from  glosso-labio-laryngeal  paral- 
ysis, as  in  fact  might  be  expected,  the  same  nerves  and  muscles  being 
involved.  Finally,  the  patient  dies  from  exhaustion,  or  from  some  in- 
tercurrent disease. 

Few  diseases  are  so  irregular  and  ununiform  in  their  phenomena  as 
the  cerebro-spinal  form  of  sclerosis.  This  is  due  to  the  fact  that  the 
organs  liable  to  be  the  seat  of  the  disease  are  numerous  and  of  varied 
functions.  The  essential  feature  of  the  affection  is  tremor  occurring 
generally  after  paralysis,  and  only  manifested  during  the  performance 
of  voluntary  movements.  It  is  not  always  necessary,  however,  that 
the  movements  should  be  of  the  partially-paralyzed  limbs,  for  I  have 
seen  cases  in  which  tremor  was  excited  in  a  paretic  leg  by  the  act  of 
executing  voluntary  movements  with  a  sound  hand. 

The  following  histories  will  contribute  to  a  fuller  understanding  of 
the  subject  : 

Cruveilhier  l  reports  the  case  of  a  cook,  aged  thirty-seven,  who  six 
years  before  coming  under  observation  noticed  that  he  was  losing  power 
in  the  left  leg,  so  that  he  nearly  fell  in  the  street.  Three  months  sub- 
sequently the  right  leg  became  similarly  affected,  and  then  the  superior 
extremities  followed.  They  were  tremulous  and  weak,  but  the  patient 
was  still  able  to  use  them  to  some  extent.  The  sensibility  remained 
intact,  and  the  reflex  faculty  of  the  cord  was  unimpaired.  In  other 
respects  the  patient  was  condemned  to  immobility.  There  were  no 
spasmodic  retractions  of  the  limbs,  and  no  painful  contractions.  The 
articulation  was  imperfect,  but  the  intelligence  was  unaffected.  There 
appear  to  have  been  no  marked  head-symptoms  in  this  case.  "  Point 
de  cephalalgie,  jamais  de  cephalalgie,  le  malade  entendait  a  merveille." 

1  "  Anatomie  pathologique  du  corps  humain,"  Paris,  1835,  1812,  tome  ii.,  liv.  xxxii., 
Fig.  4,  PI.  2. 


MULTIPLE   CEREBRO-SPINAL   SCLEROSIS.  773 

After  death  there  was  found  gray  degeneration  of  the  spinal  cord,  of 
the  medulla  oblongata,  of  the  pons  Varolii,  of  the  right  cerebral  pedun- 
cle, of  the  right  optic  thalamus,  of  the  corpora  callosa,  and  of  the  for- 
nix.    The  hemispheres  were  not  involved. 

Two  other  cases,  similar  in  general  character  to  the  foregoing,  are 
given,  in  neither  of  which  were  the  hemispheres  involved. 

Another  case,  that  of  Josephine  Pajet,  is  cited  by  C'ruveilhier.1  In 
this  there  was  almost  complete  insensibility  of  the  inferior  extremi- 
ties, though  the  patient  was  able  to  move  the  toes,  the  feet,  and  the 
legs.  There  were  no  cramps  and  no  contractions.  There  wras  also 
diminished  sensibility  of  the  superior  extremities.  All  the  limbs 
were  weak,  and  the  arms  were  affected  with  tremor.  The  patient 
could  walk  and  sew  when  first  seen.  The  right  hand  was  stronger 
than  the  left.  There  was  a  sensation  of  a  tight  band  around  the 
abdomen.  After  death  there  was  gray  degeneration  of  the  cord,  and 
of  the  pons  Varolii. 

In  none  of  these  cases  were  there  spasmodic  jerkings  or  tonic  con- 
tractions of  the  limbs.  Two  cases  have  been  reported  by  Friedreich.8 
In  one  of  these  a  man,  aged  twenty-one,  was  the  subject.  Among  the 
first  symptoms  were  mental  excitement,  vertigo,  pain  in  the  head,  and 
weakness  of  the  lower  extremities.  The  gait  was  unsteady,  and  there 
was  tremor  upon  any  emotional  excitement,  or  on  the  attempt  to  exe- 
cute movements.  This  affected  the  upper  and  lower  extremities,  the 
head,  and  the  eyeballs.  After  death,  patches  of  sclerosed  tissue  were 
found  on  the  tubercula  mammillaria,  the  cerebral  peduncles,  the  pons 
Varolii,  and  the  medulla  oblongata. 

The  other  case  was  that  of  a  woman,  aged  twenty,  who  was  attacked, 
when  seventeen  years  of  age,  with  weakness  of  the  right  leg.  Soon 
afterward  the  left  became  affected,  and  subsequently  the  arms.  These 
latter  were  rendered  tremulous  at  every  attempt  to  move  them.  The 
Bpeech  was  implicated,  and  there  was  nystagmus.  The  mind  was  weak- 
ened, and  the  sensibility  was  impaired. 

In  the  first  of  these  cases  the  disease  appears  to  have  begun  in  the 
brain  ;  in  the  second  in  the  spinal  cord. 

Vulpian,*  under  a  title  which  goes  to  show  how  even  the  best  au- 
thorities have  confused  the  whole  subject  of  sclerosis,  describes  an  in- 
ting  case  communicated  by  Charcot.     In  this  instance  a  woman, 

.  Eorty-three,  of  nervous  temperament,  bad  been  subject  to  frequent 
I  facial  neuralgia,  and  had  often  suffered  from  vague  pains 

1  Op.  <•'"'.,  liv.  ixxviii.,  Fig.  I,  PI.  5. 
«  "  Deutsche  Klinik,"  Ko.  1 1,  1 

'"Note  but  la  en  plaques  dels  moelle  epiniere,"   VUnio 

Juin   11,  1886,  p.  607.     Like  other  writers,  Vulpian,  in  thia  paper,  brings  togethei 
tfhicb  have  do  affinity  except  u  r<  ;ards  tb<  ■    in  ral  character  <>f  the  lesion. 


774  CEREBRO-SPIXAL   DISEASES. 

without  determinate  seat.  In  1856,  she  suffered  from  attacks  of  ver- 
tigo, which,  from  being  rare  at  first,  subsequently  came  on  five  or  six 
times  a  day.  Sometimes  she  fell,  but  never  lost  consciousness,  or  had 
any  convulsive  movement. 

Shortly  afterward,  during  the  night,  she  was  seized  with  vomiting, 
cramps  in  her  limbs,  and  a  numbness  of  the  right  side.  In  the  morn- 
ing she  was  hemiplegic.  Fifteen  days  afterward  motion  reappeared 
in  the  arm,  but  the  leg  remained  paralyzed.  In  1859,  she  had  anoth- 
er attack  of  hemiplegia,  and  this  time  was  deprived  of  speech  for 
fifteen  days.  After  this  seizure,  there  were  contractions  of  the  flexors 
of  the  fingers,  and  of  the  forearm  of  the  right  side.  In  1861,  she  had 
a  third  attack. 

In  1862  (January  1st)  she  came  under  M.  Charcot's  care. 

The  intellectual  faculties  were  not  involved.  The  right  superior 
extremity  was  almost  entirely  paralyzed,  and  was  in  a  state  of  rigidity 
and  contraction.  The  lower  extremities  were  permanently  extended, 
and  could  not  be  flexed  but  by  great  effort.  Sensibility  was  perfect 
throughout,  and  reflex  movements  could  still  be  excited.  She  died 
February  9th. 

On  post-mortem  examination,  patches  of  sclerosed  tissue  were  found 
in  the  right  middle  cerebral  peduncle,  the  pons  Varolii,  the  medulla  ob- 
longata, and  the  cervical  region  of  the  spinal  cord.  The  hemispheres 
were  perfectly  healthy. 

In  this  case,  it  is  probable  that  the  contractions  were  mainly  due  to 
secondary  degeneration  of  the  cord,  a  condition  which,  as  we  have  seen, 
is  analogous  to  sclerosis.  It  will  be  observed  that  there  were  no  tre- 
mors, either  with  or  without  voluntary  motions. 

Another  important  case  has  been  reported  by  M.  Magnan  :' 

A  woman,  aged  thirty-four,  came  under  observation.  In  1848, 
when  thirteen  years  of  age,  she  had  an  attack  of  typhoid  fever,  from 
which  she  lost  her  sight.  The  first  symptom  of  her  disease  occurred 
in  1867,  and  consisted  of  trembling  of  the  hands  and  arms  whenever 
she  endeavored  to  execute  any  difficult  movement.  Before  long,  the 
tremor  involved  the  lower  extremities ;  but  there  was  no  paralysis 
till  about  eight  months  previous  to  her  admission  to  the  hospital.  At 
this  time,  every  effort  at  motion  caused  tremor.  The  hands,  arms, 
legs,  eyeballs,  and  even  the  muscles  of  the  trunk,  were  involved.  The 
articulation  was  defective,  and  there  were  various  painful  sensations 
in  different  parts  of  the  body.  Ophthalmoscopic  examination  showed 
atrophy  of  the  optic  disks  and  nerves. 

The  diagnosis  in  this  case  was  multiple  cerebro-spinal  sclerosis — 
an  opinion  which  I  do  not  think  is  wan-anted  by  the  facts.  The  lesion 
was  probably  entirely  confined  to  the  brain.     The  main  reason  which 

1  "  Mcmoircs  dc  la  societe  dc  biologic,"  Paris,  18C9. 


MULTIPLE   CEREBRO-SPIXAL   SCLEROSIS.  775 

leads  me  to  entertain  this  view  is,  that  the  tremor  appeared  before  the 
paralysis. 

I  cite  the  case  for  the  purpose  of  showing  how  little  accord  there 
is  among  authors  relative  to  the  association  of  symptoms  with  lesions 
in  the  several  forms  of  sclerosis. 

Thirty-one  cases  of  what  the  symptoms  indicated  to  he  the  cerebro- 
spinal form  of  sclerosis  have  been  under  my  care  ;  and,  though  I 
have  not  had  the  opportunity  of  verifying  my  diagnosis  in  a  single 
instance,  I  think  the  symptoms  have  been  of  such  a  character  as  to 
indicate  the  existence  of  the  lesion  so  graphically  described  by  Char- 
cot,  Friedreich,  and  Bourneville  and  Guerard.1  The  fact,  that  sev- 
eral of  the  histories  were  written  out  before  Charcot's  investigations 
gave  me  a  clew  to  their  real  import,  will  tend,  I  think,  to  increase 
their  value. 

Mr.  M.,  a  gentleman  fifty-three  years  of  age,  consulted  me,  at 
the  instance  of  my  friend  Prof.  Fordyce  Barker,  M.  D.,  for  partial 
paralysis  with  tremor,  mainly  affecting  the  right  arm  and  leg. 
Two  years  previously  he  had  suffered  from  vertigo  and  headache, 
which  wen-  followed  by  a  slight  attack  of  hemiplegia  of  the  right 
side,  unattended  by  loss  of  consciousness.  lie  gradually  recovered 
from  this,  but,  about  six  months  before  he  came  under  my  observa- 
tion, he  noticed  that  his  right  leg  began  to  drag,  and,  soon  after- 
ward, that  the  arm  of  the  same  side  became  weak.  About  the  same 
time  he  hail  headache,  vertigo,  and  weakness  of  sight.  A  short 
time  subsequently — about  a  month,  as  well  as  he  could  recollect — 
the  arm  was  seized  with  tremor  while  attempting  to  carry  a  glass  of 
wine  to  his  lips.  The  agitation  continued  to  grow  more  violent  on 
any  voluntary  movement  of  the  arm,  and  gradually  his  speech  be- 
came involved. 

When  I  saw  him  he  was  still  suffering  from  occasional  attacks  of 
vertigo  and  headache  ;  the  lips  were  agitated  whenever  he  attempted 
to  move  them,  the  tongue  was  tremulous,  and  his  speech  was  conse- 
quently halting  and  jerking.  There  was  also  nystagmus,  a  symptom 
which  he  bad  no4  noticed. 

The  right  arm  was  unaffected  with  tremor  so  long  as  he  allowed  it 
to  rest  on  his  knee  or  to  hang  by  his  side  ;  but,  in  the  act  of  moving  it, 
the  whole  extremity  was  agitated  by  a  series  of  short,  vibratory  mo- 
tions, consisting  of  flexions  and  extensions,  which  continued  so  long  as 
he  ]  •  rsevered  in  the  movement,  or  kept  the  arm  in  any  position  requir- 
ing muscular  exertion.  The  right  leg  was  weak,  and  dragged  so  that 
truck  his  foot  against  any  slight  obstruction.  There  was  a  little 
tremor  in  it  when  he  attempted  to  cross  it  over  the  other  as  he  sat  in  a 
chair. 

1  "  De  la  scl6roM  en  plaq  Nbuveflc  6tode  inr  qaelques  polnl 

In  solteoM  en  plaquef  dissemio^es,"  Bourneville,  Paris,  1869. 


776  CEREBRO-SPINAL   DISEASES. 

I  treated  him  solely  with  the  primary  galvanic  current,  which  I 
passed  through  the  brain  and  spinal  cord — the  first  time  such  an  oper- 
ation was  performed  in  this  country  for  the  treatment  of  disease.  My 
diagnosis  was  incipient  softening  of  the  ganglia  at  the  base  of  the  brain 
and  of  the  upper  portion  of  the  spinal  cord.  My  opinion  was,  that 
the  hemispheres  were  not  involved,  as  there  were  no  symptoms  indicat- 
ing mental  weakness  or  disturbance. 

I  made  an  application  of  about  fifteen  minutes'  duration  every  day. 
He  gradually  but  rapidly  improved,  and  to  such  an  extent  that  on  the 
19th  of  April  he  wrote  to  me  as  follows  : 

"  Yesterday  must  be  marked  with  a  white  stone  as  the  best  day  yet. 
Foot  active,  hand  and  arm  steady,  and  spirits  good.  If  we  can  manage 
to  fix  these  good  effects,  cure  is  certain. 

"  I  hope  the  magic  pile  will  be  ready  to  repeat  its  good  work  on 
Saturday  next." 

He  continued  to  improve  for  several  weeks,  then  gradually  went 
back  to  his  former  condition,  and  from  that  rapidly  grew  worse.  The 
paralysis  invaded  the  other  side,  then  tremor  followed,  the  speech 
became  much  more  difficult,  and  he  died  in  the  country  two  years  sub- 
sequently. 

Miss  II.,  of  Connecticut,  aged  thirty-five,  consulted  me  for  paralysis 
and  tremor.  About  two  years  previously,  she  had  noticed  a  weakness 
of  the  right  arm,  which  had  been  preceded  by  occasional  attacks  of 
not  very  severe  headache  and  vertigo.  The  arm  gradually  became 
weaker,  and  in  the  course  of  a  few  months  began  to  shake  whenever 
she  attempted  to  use  it.  Before  the  year  had  expired,  the  right  leg 
began  to  drag  a  little,  and  lost  a  good  deal  of  its  natural  strength. 
Her  speech  also  became  difficult,  not  from  any  failure  to  remember 
words,  but  from  tremor  of  the  tongue  and  weakness,  with  a  little  rigid- 
ity of  the  lips. 

When  I  saw  her,  the  articulation  was  halting  and  syllabic ;  there 
was  nystagmus  in  both  eyes  ;  the  right  arm  was  very  weak  ;  she  could 
only  move  the  index  of  my  dynamometer  four  degrees,  equivalent  to 
a  pressure  of  two  pounds  and  a  half,  while  with  the  left  hand  she 
could  move  it  twenty-eight  degrees.  Every  attempt  to  move  the  arm 
caused  trembling  of  the  whole  extremity.  So  long  as  she  refrained 
from  any  exertion  of  voluntary  power,  it  remained  free  from  agitation. 
She  could  not  write,  owing  to  the  tremor  which  the  effort  to  do  so 
excited.  There  was  slight  tremor  in  the  leg,  when  she  slowly  raised  the 
foot  from  the  ground. 

The  mind  was  perfectly  intact,  and  she  was  entirely  free  from  any 
emotional  weakness. 

In  this  lady's  case  I  diagnosticated  multiple  eerebro-spinal  sclerosis 
—the  "sclerose  en  plaques  disseminees"  of  Charcot. 

I  treated  her  with  the  iodide  of  potassium  and  the  primary  gal- 


MULTIPLE   CEREBRO-SPIXAL   SCLEROSIS.  777 

vanic  current.  I>y  the  following  autumn  she  had  improved  so  much 
that  she  could  walk  several  miles  without  fatigue,  lifted  her  foot  clear 
of  the  ground,  could  move  the  index  of  the  dynamometer  to  thirty 
degrees,  was  free  from  tremor,  except  when  she  attempted  to  write, 
and  then  it  was  only  manifested  to  a  slight  extent.  I  now  ceased 
using  the  galvanism,  but  continued  the  iodide  of  potassium.  One 
year  later  she  paid  me  a  visit.  She  was  then  walking  well,  but  there 
was  still  a  very  slight  tremor  when  she  attempted  to  execute  delicate 
or  difficult  movements  with  the  right  arm.  I  directed  the  continu- 
ance of  the  iodide. 

Mr.  II.,  of  South  Carolina,  a  highly-educated  and  intelligent  gen- 
tleman, consulted  me  for  paralysis  and  tremor.  As  he  entered  my 
consulting-room,  the  tendency  to  festination  was  exceedingly  well 
marked.  On  examination,  I  found  his  mind  perfectly  clear.  There 
were  nystagmus  and  syllabic  articulation.  On  moving  the  left  arm  or 
left  or  right  leg,  the  limb  became  tremulous.  There  had  never  been 
any  head-symptoms. 

One  week  later,  at  my  request,  he  wrote  a  short  account  of  his  dis- 
which  I  here  transcribe  : 

"I  was  never  robust  in  health,  but,  on  the  other  hand,  I  have  never 
had,  since  childhood,  a  serious  spell  of  sickness.  My  manner  of  life 
has  brcn  sedentary — that  of  a  student.  I  was  always  careful  not  to 
overtask  myself  until  I  became  engaged,  in  the  year  1  — ■  *  *  t ,  in  a  mathe- 
matical research.  I  was  for  a  considerable  length  of  time  very  much 
absorbed  in  this  work,  and  allowed  it  to  encroach  seriously  upon  my 
hours  of  recreation  and  sleep. 

"In  the  fall  of  L865,  after  having  accomplished  the  above  work,  T 
observed  a  slight  lameness  in  my  left  foot — a  tendency  to  strike  the 

against  the  inequalities  of  the  ground — an  inability  to  raise  quickly 
enough  the  front  part  of  the  foot. 

"After  my  return  home,  in  the  summer  of  l^(if>.  from  Europe, 
where  1  had  spent  live  or  six  years,  the  lameness  in  my  foot  in- 
creased rapidly,  ami  in  the  winter  of  1866-,6'J  a  lameness  in  my 
left  hand  was  very  perceptible— an  inability  to  mov<  the  fingers 
quickly,  and  a  tremor,  particularly  of  the  thumb,  when   I  attempted 

to   do   BO. 

"  The  above  symptoms  have  gradually  gTOWti  worse,  and  within  the 

la -a  year  the  right  leg  has  become  involved,  to  the  extent  that  it  begins 

to  -hake  when  I  -land  upon  it,  and  it  shakes  even  while  sitting,  when  ! 
am  under  excitement,  or  when  I  execute  difficult  voluntary  motions 
with  my  hands. 

"The  dif  ems  to  make  greater  progress  in  hot  weather.     I 

have  at  no  time  Buffered  pain,  my  appetite  and  digestion  are  good, and 

I  generally  Bleep  well." 

This  gentleman  improved  greatly  through  the  use  of  the  primary 


778  CEREBRO-SPINAL   DISEASES. 

galvanic  current,  iodide  of  potassium,  and  tincture  of  hyoscyamus, 
during  the  two  weeks  that  he  remained  in  New  York  under  my 
care.  On  bis  return  to  South  Carolina  he  took  a  primary-cell  battery 
wi1  li  birn. 

Four  months  later  be  wrote  to  me  as  follows  : 

"Sometimes  I  thought  I  was  improving  slowly,  or  at  any  rate  not 
losing  ground,  and  then  again,  for  several  days  together,  I  would  feel 
confident  that  I  was  falling  back.  But  now  I  think  I  can  certainly  say 
I  am  growing  worse.  All  -my  symptoms  have  been  worse — lamer,  more 
nervous,  and  the  disease  more  general  in  its  effects.  My  right  hand, 
which  has  heretofore  been  comparatively  unaffected,  is  now  seriously 
implicated,  and  yet  I  still  manage  to  write' after  a  fashion.  I  find  it 
very  difficult  to  dress  myself,  and  I  must  make  several  attempts  before 
I  can  get  up  from  a  sitting  or  a  lying  posture. 

"  What  could  have  caused  the  improvement  that  took  place  while 
I  was  under  your  immediate  treatment?" 

In  this  case  I  diagnosticated  multiple  cerebro-spinal  sclerosis,  and 
I  think  those  acquainted  with  the  disease  will  agree  with  me  in  my 
view  of  the  case  ;  and  yet  there  was  as  strongly-marked  festination 
as  I  have  ever  seen.  The  gentleman  could  trot  well,  could  mount  a 
staircase  without  much  difficulty,  but  walking  slowly,  or  descending 
stairs,  troubled  him  greatly.  According  to  some  authors,  this  symptom 
would,  of  itself,  have  been  sufficient  to  contraindicate  the  existence  of 
sclerosis,  and  to  have  placed  the  disease  among  the  neuroses.  My 
views  on  this  point  have  already  been  expressed  under  the  head  of 
multiple  cerebral  sclerosis. 

J.  F.,  a  gentleman  of  this  city,  forty-two  years  of  age,  consulted  me 
November  29,  1870.  On  the  4th  of  July  previously  he  had  indulged 
rather  freely  in  champagne,  and  the  following  morning  awoke  with 
severe  headache,  vertigo,  and  nausea.  Although  he  recovered  from 
this  attack,  he  never  felt  quite  as  well  as  before,  and  was  frequently 
subject  to  headache  and  vertigo — symptomatic,  as  he  thought,  of 
gastric  disorder.  About  a  month  after  his  first  symptoms  he  was  sud- 
denly conscious  of  a  singular  sensation  about  his  left  eye,  and  on  look- 
ing in  the  glass  discovered  that  the  upper  lid  had  dropped,  and  that  he 
could  not  raise  it.  This  was  about  five  o'clock  in  the  afternoon,  and  by 
ten  that  night  the  lid  entirely  covered  the  pupil.  The  following  morn- 
ing it  was  not  so  low,  but  he  found  that  he  saw  double.  He  continued 
to  attribute  all  his  troubles  to  the  stomach,  and  began  taking  some  quack 
remedy  recommended  to  him  for  dyspepsia. 

In  the  course  of  a  few  days,  feeling  no  better,  he  went  to  the  sea- 
shore, and  while  there  noticed  that  his  right  arm  became  weak,  and  that 
he  frequently  let  things  drop  from  his  hand.  He  had  difficulty  in  shav- 
ing and  in  dressing  himself,  from  inability  to  coordinate  the  muscles, 
and   there   was   numbness  of  the   ends  of   the  finders.     During  all  this 


MULTIPLE   CEREBRO-SriXAL   SCLEROSIS.  779 

time  he  bad  suffered  more  or  less  from  headache,  vertigo,  and  double 
vision,  and  the  ptosis  still  continued.  Gradually  the  left  arm  became 
involved,  and,  by  the  time  the  paresis  in  this  extremity  was  well  estab- 
lished, the  right  arm  was  affected  with  tremor,  but  only  when  he  at- 
tempted to  execute  movements  with  it.  Thus,  as  he  said,  he  could 
place  the  hand  on  a  table  and  it  would  continue  perfectly  quiet  ;  but, 
as  soon  as  he  took  a  pen  to  write,  or  even  endeavored  to  raise  the  hand 
from  the  table,  it  was  seized  with  tremor.  The  left  arm  soon  became 
similarly  affected,  and  eventually  the  left  leg  lost  strength  and  was 
rendered  tremulous  by  any  attempt  at  muscular  exertion.  He  noticed 
also,  what,  as  I  afterward  learned,  his  friends  had  perceived  several 
weeks  before,  that  his  articulation  was  imperfect,  and  that  is  was  ne- 
cessary for  him  to  make  a  mental  effort  to  talk  distinctly. 

He  returned  to  the  city  about  the  middle  of  October,  and  employed 
a  "  rubber  "  to  restore,  as  he  said,  the  circulation  to  his  limbs.  Con- 
tinuing to  get  worse,  he  consulted  me. 

At  this  time  there  was  festination.  The  speech  was  syllabic  and 
toe  ntuated,  the  tongue  and  lips  were  paretic  and  tremulous,  there  was 
nystagmus  in  both  eyes,  ptosis  and  diplopia  from  paralysis  of  the  left 
sixth  nerve,  and  dilated  pupil  of  the  right  eye.  There  were  also  occa- 
sional headache  and  vertigo,  but  not  to  the  same  extent  as  at  first. 

Both  arms  and  the  left  leg  were  partially  paralyzed.  He  could  not 
raise  either  upper  extremity  out  from  the  side,  owing  to  the  complete 
paralysis  of  the  deltoids,  but  he  could  flex  both  forearms,  and  move  his 
bands  and  fingers  tolerably  well.  There  was  no  tremor  while  he  re- 
frained from  using  them,  but  the  least  attempt  at  voluntary  motion 
excited  them  to  agitation.  The  same  was  true  of  the  left  leg.  Exami- 
nation with  the  ophthalmoscope  showed  both  optic  disks  to  be  white, 
and  the  retinal  vessels  small  and  straight. 

With  the  dvnamometer  he  could  only  exert  a  pressure  of  nine  de- 
grees  with  the  right  hand  and  eleven  with  the  left.  The  line  made 
with  the  dynamograph  was  descending,  showing  his  inability  to  main- 
tain,  even  for  B  short  time,  a  uniform  muscular  contraction. 

There  was  no  loss  of  sensibility,  except  in  the  upper  extremities. 
lie  had  occasionally  Buffered  from  pains  in  the  back,  about  the  region 
of  t  lie  shoulders. 

Tin-  pow<  r  ov(  r  the  sphincters  was  intact. 

This    gentleman    Could    stand  and  walk   as  well  with  his  eyes  shut   as 

with  them  open.     On  rising  from  his  chair,  which  he  did  with  difficulty, 

IwayS  fell    impelled  to  take  a   few  steps  forward,  which  were  a  stag- 

i  ither  than  a  voluntary  movement.  In  walking,  the  body  was  in- 
clined forward,  and  he  went  in  a  kind  of  jog-trot. 

He  attributed  his  disease  to  dissipation  of  all  kinds,  in  which  opinion 
I  expressed  ray  c  >ncurren< 

Under  treatment  with  galvanism,  byosoyamus,  and  iodide  ^i'  potas- 


780  CEREBRO-SHNAL   DISEASES. 

sium,  this  patient  has  improved,  but  not  as  yet  sufficiently  to  warrant 
any  strong1  hope  of  a  permanent  cure. 

A  gentleman  from  the  northern  part  of  the  State  of  New  York  con- 
sulted me  in  January,  1871,  and  again  in  March.  His  symptoms,  though 
decided,  were  not  very  severe  in  character.  Gradually,  however,  there 
had  been  for  two  years  a  loss  of  power  supervening  in  the  muscles  of 
the  right  side  of  the  body,  and  lately  ocular  troubles  had  made  their  ap- 
pearance. Tremor,  on  making  any  voluntary  movement,  was  just  be- 
ginning to  appear  when  I  last  saAV  him.  Its  influence  over  his  hand- 
writing is  seen  in  the  following  facsimile: 

Fig.  113. 


One  patient,  with  multiple  cerebro-spinal  sclerosis,  attends  the  out- 
door department  of  the  New  York  State  Hospital  for  Diseases  of  the 
Nervous  System.  He  has  marked  head-symptoms.  And  another,  from 
Philadelphia,  who  was  supposed  to  be  suffering  from  cerebral  disease, 
consulted  me  a  few  days  ago.  In  this  case  the  affection  probably  re- 
sulted from  a  fall. 

The  remaining  cases  do  not  present  any  such  peculiar  phenomena 
as  to  warrant  their  histories  being  given  in  detail. 

Causes. — Nothing  very  definite  is  known  of  the  etiolog}r  of  the  affec- 
tion in  question.  It  probably  is  induced  by  such  causes  as  give  rise  to 
the  purely  cerebral  form  of  the  disease.  Age  does  not,  however,  ap- 
pear to  exercise  so  important  an  influence.  Eleven  of  my  cases  were 
over  fifty  years,  and  one  of  them,  the  gentleman  from  Philadelphia, 
was  over  sixty  ;  seventeen  were  over  forty  and  under  fifty,  and  three 
were  between  thirty  and  forty.     All  were  males  but  four. 

In  seven  cases  it  was  apparently  caused  by  excessive  mental  appli- 
cation, in  two  by  anxiety,  in  one  by  a  fall,  in  six  by  dissipation.  In 
the  remaining  cases  I  could  discover  no  obvious  cause.  In  none  of 
them  was  there  a  rheumatic,  syphilitic,  or  other  morbid  diathesis. 

Diagnosis. — The  facts  of  the  tremor  making  its  appeai-ance  after  the 
paralysis,  and  of  its  only — or,  at  least,  with  rare  exceptions,  and  then 
only  in  the  latter  stages  of  the  disease — being  manifested  when  volun- 
tary movements  are  being  made,  will  suffice  to  distinguish  the  cerebro- 
spinal form  of  sclerosis  from  any  other  affection.  The  points  to  recol- 
lect are  these :  that,  in  paralysis  agitans,  the  tremor  appears  before 
the  paralysis,  and  does  not  depend  on  the  voluntary  contraction  of 
muscles  for  its  excitation.  The  tremor  is  rhythmical,  and  the  muscu- 
lar movements  are  performed  slowly  on  account  of  the  stiffness  and 
contraction  of  the  muscles  :  In  simple  spinal  sclerosis  there  is  no  tremor 


MULTIPLE   CEREBRO-SPINAL   SCLEROSIS.  781 

at  all.  I  have  already  insisted  on  these  distinctions  in  my  remarks  on 
the  other  forms  of  sclerosis  of  the  nervous  centres. 

Prognosis. — This  is  very  generally  unfavorable.  In  only  one  case 
have  I  had  reason  to  expect  a  cure.  It  often  happens  that  amendment 
very  decided  in  its  character  takes  place  soon  after  the  beginning  of  the 
treatment  with  galvanism  and  hyoscyamus.  This  has  been  the  case 
in  every  instance  of  the  disease  that  has  been  under  my  charge  ;  but 
in  only  one  has  it  been  permanent.  In  those  now  under  treatment, 
there  has  as  yet  been  no  relapse  ;  but  the  time  is  too  short  to  speak 
with  any  confidence  in  regard  to  the  ultimate  result. 

Morbid  Anatomy  and  Pathology. — The  remarks  made  under  this 
head,  when  the  cerebral  and  spinal  forms  of  sclerosis  were  being  con- 
sidered, apply  to  the  cerebrospinal  variety.  Charcot1  has  considered 
the  subject  of  sclerosis  mainly  in  its  histological  relations.  The  main 
points  are — and  these  have  already  been  stated  several  times — that  the 
morbid  process  essentially  consists  in  hypertrophy  of  the  neuroglia  at 
the  expense  of  the  proper  nerve-substance,  and  that  this  is  a  conse- 
quence of  inflammatory  action.  In  the  present  form  of  the  disease,  the 
sclerosed  1  issue  appears  in  the  form  of  plates  or  nodules  in  different 
parts  of  the  brain  and  spinal  cord. 

Treatment. — The  treatment  of  multiple  cerebrospinal  sclerosis  is 
more  palliative  than  curative.  Galvanism  to  the  brain  and  vertebral 
column,  iodide  of  potassium,  nitrate  of  silver,  and  preparations  of  hyos- 
cyamus, have  very  generally  caused  improvement  for  a  time,  but  my 
rience  goes  to  show  that  this  is  not  permanent. 

The  galvanic  current  should  be  used  of  less  tension  when  applied 
to  the  head,  but  as  strong  as  the  patient  can  endure,  to  the  spine. 

Tin  iodide  of  potassium,  which,  I  believe,  prevents  to  a  certain  ex- 
tent the  formation  of  new  connective  tissue,  should  be  given  in  mod- 
erate doses  at  first,  but  should  be  gradually  increased  up  to  the  point 
of  toleration. 

I  have  sometimes  given  the  nitrate  of  silver  in  fourth-of-a-gram 
■  loses,  three  times  a  day,  and  very  generally  recommend  cod-liver  oil 
with  each  meal.  Occasionally  I  have  also  administered  the  bichloride 
of  niereiis-v.  with  the  view  of  counteracting  a  possible  syphilitic  dia- 
thesis v- 

Hyoscyamine  maybe  advantageously  employed,  according  to  the 
formula  given  on  page  298,  for  the  treatment  of  paralysis  agitans. 

Whatever  measures  are  adopted  should  be  continued  for  several 
mouths  at   least,  and,  if  the  improvement   persists,  for  a  much  lot 

period. 

'  <;,,-,!!,  dm  Hdpitaux,  Nos.  102,  108,  1  I",  1 11,  l  i::.     186a 


782  CEREBRO-SPINAL   DISEASES. 

CHAPTER   VIII. 

PARETIC  TREMOR. 

The  affection  which  Parkinson1  described,  and  to  which  he  applied 
the  name  "  shaking  palsy,"  has  since  been  very  carefully  studied  by 
many  writers,  and  the  fact  has  been  clearly  made  out  that  it  is  not  a 
single  disease,  but  includes  several  affections  wThich  are  very  different 
in  character.  I  have  already  considered  two  of  them — paralysis  agi- 
tans  and  multiple  cerebro-spinal  sclerosis ;  a  third  I  propose  to  treat 
under  the  name  of  paretic  tremor. 

Symptoms. — The  primary  manifestation  is  tremor,  and  this,  like  the 
same  symptom  in  the  severer  forms  of  disease  already  considered,  in 
which  it  forms  an  essential  feature,  may  begin  in  a  very  restricted  or 
more  extensive  region  of  the  body.  It  is  present  whether  voluntary 
movements  are  performed  or  not  with  the  affected  limbs,  but  is  in- 
creased by  mental  excitement  of  any  kind,  by  physical  exertion,  or  by 
any  cause  capable  of  depressing  the  powers  of  the  system. 

It  is  not  generally  the  case  that  the  tremor  shows  any  tendency  to 
advance  much  beyond  its  original  limits,  however  small  or  extensive 
these  may  be.  When  it  does  exhibit  such  a  disposition,  contiguous 
muscles  are  first  attacked,  and  then  the  corresponding  ones  on  the  oppo- 
site side  of  the  body. 

From  the  very  first  there  is  slight  muscular  weakness,  not  to  any 
very  great  extent,  and  often  not  severe  enough  to  attract  the  patient's 
attention,  but  still  sufficiently  evident  to  careful  examination  with  the 
dynamometer.  As  the  tremor  increases  in  violence  or  extent,  the 
paralysis  becomes  more  obvious. 

Sensibility  is  rarely  affected,  there  is  no  bending  of  the  body  for- 
waid,  no  festination,  and  no  head-symptoms.  The  tremor  always  ceases 
during  sleep,  except  in  very  extreme  and  long-continued  cases,  and 
there  may  be  intermissions  of  longer  or  shorter  duration  while  the 
patient  is  awake. 

Causes. — Paretic  tremor  may  result  from  emotional  disturbance, 
from  continuous  or  severe  muscular  exertion,  from  some  exhausting 
disease,  such  as  dysentery,  typhoid  or  typhus  fever,  or  rheumatism,  or 
from  blows,  falls,  or  other  injuries.  In  many  cases  the  cause  cannot 
be  ascertained. 

Of  twenty-five  cases  of  which  I  have  records,  ten  were  apparently 
due  to  mental  causes,  four  to  excessive  physical  exert  ion,  four  to  dis- 
eases  of  various  kinds,  two  to  injuries,  and  in  five  no  cause  could  be 
discovered. 

Two  cases  of  mercurial  trembling,  the  symptoms  of  which  affection 

1  "Essay  on  the  Shaking  Palsy,"  London,  1817. 


PARETIC   TREMOR.  783 

are  very  similar  to  those  of  non-toxic  paralysis  agitans,  are  not  included 
among  the  foregoing. 

Diagnosis.  —  From  paralysis  agitans,  paretic  tremor  is  distin- 
guished by  the  facts  that  there  are  no  head-symptoms,  no  festina- 
tion,  and  no  derangements  of  sensibility.  It  is  more  apt  to  occur  in 
persons  under  the  age  of  fifty,  and  may  be  met  with  in  quite  young 
persons.  The  reverse  of  both  these  circumstances  is  true  of  paralysis 
agitans. 

From  multiple  cerebro-spinal  sclerosis,  it  is  diagnosticated  mainly 
by  the  absence  of  any  head-symptoms,  by  the  fact  that  the  tremor  usu- 
ally comes  on  before  the  paralysis,  and  is  independent  of  voluntary 
movements. 

From  convulsive  tremor  it  is  readily  distinguished  by  the  facts  that 
the  tremor  is  not  paroxysmal,  and  that  it  is  accompanied  by  paresis  of 
the  affected  muscles. 

The  character  of  the  muscular  action,  and  the  history  of  the  case, 
will  prevent  its  being  confounded  with  chorea. 

Prognosis. — Paretic  tremor  rarely  terminates  fatally,  and  when  it 
does  it  is  because  the  tremor  has  become  so  general  that  death  results 
from  exhaustion.  It,  however,  often  happens  that  all  measures  fail  to 
relieve  the  agitation.  Of  the  twenty-five  cases  occurring  in  my  own 
experience,  eight  were  cured,  five  partially  so,  and  in  the  rest  no  per- 
manent effect  was  produced  by  any  means  I  employed. 

Morbid  Anatomy  and  Pathology. — Nothing  is  known  of  the  morbid 
anatomy.  In  a  few  cases,  patients  have  died  either  from  the  disease  or 
from  some  intercurrent  affection,  and  post-mortem  examinations  have 
been  made  with  negative  results.  Petrams,  quoted  by  Dr.  Handheld 
Jones,  relates  two  severe  cases,  one  of  which  proved  fatal.  At  the 
autopsy  nothing  was  found  but  fatty  degeneration  of  the  heart  and 
pneumonic  consolidation  of  the  right  lung.  He  remarks  on  the  tremor 
r.nf  being  constant  in  many  cases,  ceasing  for  some  days  and  then  re- 
turning with  fresh  force,  or  changing  its  scat  from  one  part  to  another. 

In  my  opinion,  the  disease  under  consideration  is  due  to  an  irregular 
and  diminished  evolution  of  nerve-force  from  the  motor  nerve-cells  in 
illation  with  the  nerves  supplying  the  muscles  in  which  the  agitation 
exists.  The  pathology  of  tremor,  not  the  result  of  structural  lesions,  is 
a  subject  which  is  beginning  to  be  studied,  but  which  is  not  yet  clearly 
understood.  We  know  that,  when  we  have  strongly  exerted  an  arm, 
for  instance,  the  muscles  are  tremulous  for  some  time  afterward,  and 
that  the  agitation  is  rendered  very  evident  when  we  attempt  to  write 
or  do  any  other  sot  requiring  delicate  muscular  adaptation,  A  period 
of  rest,  must  fake  place  before  steadiness  is  regained.  Now,  in  such 
a  case  the  agitation  is  not  probably  due  to  any  cause  inherent  in  the 
muscle,  hut  is  die  result  of  exhaustion  in  the  nerve-cells  and  the 
disengagement  of  insufficient  force  in  an  intermittent  manner.     I  sup- 


7S4  CEREBRO-SPINAL   DISEASES. 

pose  paretic  tremor  to  be  due  to  some  such  action  in  the  motor  nerve- 
cells  in  the  gray  matter  of  the  spinal  cord. 

In  those  cases  in  which  the  tremor  becomes  permanent,  structural 
lesions  of  profound  character — as  in  permanent  hysterical  contractions 
and  epilepsy — doubtless  occur. 

Treatment. — I  have  used  electricity,  both  of  the  galvanic  and  fara- 
daic  kinds,  in  all  the  cases  of  paretic  tremor  that  have  been  under  my 
charge,  and  in  conjunction  have  employed  many  internal  medicines, 
such  as  arsenic,  iron,  manganese,  zinc,  copper,  phosphorus,  strychnia, 
and  sedatives  of  various  kinds,  including  opium,  bromide  of  potassium, 
conium,  stramonium,  Indian  hemp,  and  many  others.  I  am  very  de- 
cidedly of  the  opinion  that  the  best  treatment  consists  in  the  use  of  the 
constant  primary  current  to  the  spinal  cord,  sympathetic  nerve,  and  the 
affected  muscles,  while  at  the  same  time  strychnia  and  phosphorus,  ac- 
cording to  the  formula  given  on  page  67,  are  administered  internally. 
By  these  means  four  of  my  eight  successful  cases  were  entirely  cured 
within  two  months.  One  of  these  was  sent  to  me  by  my  friend  Dr.  F. 
N.  Otis.  The  affection  was  confined  to  the  right  arm,  and  was  probably 
due  to  inordinate  gymnastic  exercise;  the  other  was  a  gentleman  from 
St.  Louis,  in  whom  the  disease  was  also  confined  to  the  right  arm,  and 
had  apparently  resulted  from  writing  excessively.  Both  had  lasted 
several  months. 

Another  was  a  railway  engineer,  in  whom  the  disease  was  the  result 
of  over-mental  excitement;  and  the  fourth  was  a  distinguished  clergy- 
man of  the  Catholic  Church  in  whom  a  like  origin  existed. 

The  six  other  cases  were,  two  of  them,  consequent  on  other  diseases, 
and  four  were  without  known  cause.  Three  were  women  ;  the  tremor 
in  two  was  in  both  arms,  and  in  two  in  one  leg  in  each.  The  duration 
of  the  treatment  was  from  three  to  seven  months.  A  full  and  nutri- 
tious diet,  and  the  avoidance  of  all  mental  excitement  or  strong  physi- 
cal exertion,  are  important  features  in  the  treatment. 


CHAPTER  IX. 

AXAPE1RATIC  PARALYSIS. 

There  is  a  class  of  paralyses  produced  by  the  habitual  use  of  a  par- 
ticular class  of  muscles  in  the  same  way  for  a  long  time.  Thus  we  havo 
writer's  paralysis,  telegrapher's  paralysis,  hammer  paralysis,  and  so  on. 
To  describe  these  as  separate  and  distinct  affections  is  scarcely,  in  the 
present  state  of  our  knowledge,  permissible.  I  shall,  therefore,  em- 
brace these  under  the  designation  of  anapeiratic   (hvarreipao),  to  do  or 


AXAPEIRATIC   PARALYSIS.  785 

attempt  again)  paralysis,  as  being  caused  by  the  frequent  repetition  of 
some  particular  muscular  action. 

Symptoms. — The  first  symptom  usually  observed  is  a  feeling  of  fa- 
tigue experienced  in  the  muscles  which  have  been  grouped  together 
for  frequent  use  in  some  especial  way.  Thus  in  writers,  engravers, 
violinists,  type-setters,  and  telegraphers,  the  tired  sensation  is  felt  in 
the  muscles  of  the  hand,  forearm,  arm,  and  shoulder.  The  thumb  is 
especially  affected,  and  is  also  the  seat  of  a  dull,  aching  pain.  Pains, 
not  very  severe  or  fixed,  are  also  common  in  the  muscles  higher  up  ; 
this  fatigue  the  patient  endeavors  to  correct  by  grasping  the  pen  or 
burin,  for  instance,  more  firmly,  or  by  making  an  intense  mental  effort 
to  regulate  the  muscular  contractions  by  which  the  instruments  are 
held,  the  type  seized,  or  by  which  the  fingers  are  moved  over  the  strings 
of  the  violin,  or  the  lever  of  the  telegraph-instrument.  But  he  only 
thereby  adds  to  the  difficulty,  for  the  weariness  and  pain  are  increased, 
the  muscles  become  weakened,  and  moreover  irregular  and  incoordi- 
nate actions  ensue  which  render  the  results  of  either  writing,  engraving, 
etc.,  more  or  less  imperfect. 

If  he  perseveres  day  after  day  in  his  occupation  he  soon  reaches 
that  stage  of  the  disease  in  which  the  ability  to  direct  the  pen,  for  in- 
stance, in  accordance  with  his  will,  is  lost,  and  the  automatic  actions, 
which  are  of  great  importance  in  writing,  are  likewise  very  much  di- 
minished. For  a  time,  then,  he  writes  better  when  his  mind  is  not 
occupied  in  directing  the  formation  of  every  letter,  but  in  which  he 
allows  the  muscles  as  it  were  to  take  care  of  themselves.  Constantly, 
however,  he  feels  the  necessity  of  mental  action,  and  this  action  invari- 
ably increases  the  trouble,  until,  at  last,  the  moment  the  attempt  is 
made  to  write,  the  pen,  actuated  by  the  muscles  of  the  fingers,  executes 
such  disorderly  movements  as  to  bear,  in  extreme  cases,  little  or  no 
analogy  to  the  words  attempted  to  be  written.  A  distinct  paroxysm 
is  thus  induced,  which  lasts  as  long  as  t  ho  patient  persists  in  t  be  attempt 
rite,  When  he  discontinues,  the  spasm  ceases,  and  lie  can  perform 
any  other  act  with  the  lingers  without  there  being  the  slightest  convul- 
sive movements.  In  some  cases  there  is  pain  in  the  fingers,  the  muscles 
between  the  metacarpal  bones,  and  in  those  of  the  forearm.  The  spasm 
is  much  worse  if  t  he  patient   be  excited  or  part  LOularly  anxious  to  do  his 

In    the   accompanying   woodcut  (Fig.  Ill)  are    represented  three 

opts   <>f   a    patient    to  write  the  name   ".lames  Ely."      At   I 
mblanoe   to   the   letter  ./  is   made,  lint  in  the  second  trial   it    is 
distinct,  and  in  the  third  is  lost  altogether. 

All  of  my  patients  had  resort  eel  to  various  expedients  to  obviate  the 

is,  under  the  idea  that   they  were  produced  by  metallic  pens  carry- 
ing oil'  the   electricity    from  the  arm  ;   several  ha  1,  for  a  time,  made  us,- 

of   .pulls,  or  hard  rubber  pens,  and   for  a   time   relief  had   been 


786 


CEREBRO-SPINAL   DISEASES. 


tained,  but  the  paroxysms  soon  became  as  bad  as  ever.  Others  had 
used  very  thick  pen-holders,  and  this  expedient  was  also,  for  a  time, 
successful.  In  the  end,  however,  all  such  efforts  to  prevent  the  spasms 
proved  futile. 

In  one  case  under  my  charge,  the  patient,  an  engraver,  was  utterly 
incapable  of  using  his  burin,  although  he  could  write  for  hours  perfect- 


Fio.  114. 


ly  well,  and  those  who  had  contracted  the  disease  by  excessive  writing 
could  execute  any  other  delicate  movements,  such  as  drawing,  playing 
the  piano  or  violin,  threading  needles,  etc.,  without  inconvenience.  In 
several  cases  the  individuals  had  acquired  the  power  to  write  with  the 
left  hand,  but  before  long  this  was  also  affected. 

Dr.  G.  V.  Poore  '  has  recently  published  an  interesting  memoir  on 
the  affection  as  produced  by  excessive  writing,  and  argues  that,  although 
it  is  true  that  patients  can  execute  other  actions  than  writing  with  the 
sted  liaml,  the  muscles  employed  in  these  movements  are  not  the 
same  as  those  used  in  writing.  This  is  doubtless  true  of  advanced 
stages  of  the  disease,  but  it  certainly  is  not  so  of  early  periods.  I  have 
a  patient  at  this  time  under  my  charge  who  cannot  write  without  great 
inconvenience,  but  who  uses  a  pencil  in  drawing  with  the  greatest  fa- 
cility and  precision. 

Dr.   Frank  Smith  2  describes  the  disease  1  have  designated  anapei- 

1  "Writers'  Cramp,  its  Pathology  and  Treatment,"  The  Practitioner,  June,  July,  and 
August,  1st:;. 

2  Lancet,  March  27,  1869,  also  "On  Hephaestic  Hemiplegia  or  Hammer  Palsy,"  British 
Medical  Journal,  October  81,  1874. 


ANAPEIRATIC   DISEASES.  787 

ratic  paralysis,  as  it  occurs  in  workmen  Mho  use  the  hammer  almost 
continually  in  certain  processes,  and  gives  it  the  name  of  hephsestic 
(llcpaiorog,  Vulcan)  hemiplegia. 

"  There  are  numerous  varieties  of  manufactures  in  which  the  rapid 
use  of  a  light  or  heavy  hammer  plays  a  chief  part,  such  for  example  aa 
table-blade  forging,  scissors-making,  saw-straightening,  razor-blade 
striking,  engineering,  file-forging,  etc." 

"  The  pen-blade  forger  uses  a  hammer  about  three  pounds  in  weight. 
A  pen-blade  receives  in  the  process  of  forging  and  joining  to  the  piece 
of  iron  by  which  it  is  attached  to  the  haft,  on  an  average,  one  hun- 
dred blows.  The  forger,  if  an  industrious  man,  anxious  perhaps  to  save, 
by  working  overtime,  enough  money  to  join  a  building-society,  or  to 
commence  business  on  his  own  account,  will  work  twelve  or  thirteen 
hours  a  day.  He  will  make  as  many  as  twenty-four  dozen  blades  in  a 
day,  and  in  so  doing  will  deliver  twenty-eight  thousand  eight  hundred 
accurate  strokes.  The  rapidity  and  accuracy  with  which  these  blows 
rain  upon  the  slender  piece  of  iron  are  wonderful  to  the  onlooker.  Sup- 
posing him  to  work  three  hundred  days  in  a  year,  and  to  continue  this 
for  ten  years,  he  will  in  that  period  have  delivered  eighty -eight  million 
four  hundred  thousand  strokes,  and  just  so  many  discharges  of  nerve- 
force  will  have  occurred  in  the  motor  ganglia  which  are  engaged  in 
the  action,  and  in  the  higher  ganglia  which  calculate  the  distance  and 
judge  of  the  amount  of  force  necessary  to  be  evolved." 

In  several  of  the  cases  adduced  by  Dr.  Frank  Smith  there  were 
head-symptoms,  and  in  all  more  or  less  extensive  hemiplegic  paralysis. 
There  were  also  twitchings  of  muscles,  pains,  and  difficulty  of  speech, 
in  some  of  the  cases. 

M.  Onimus1  was,  I  think,  the  first  to  call  attention  to  the  disease  as 
met  with  in  telegraph-operators.  The  trouble  appears  usually  to  mani- 
,  in  the  first  place  by  a  difficulty  in  coordinating  the  muscles  so 
as  to  make  dots  or  points  with  the  instrument.  After  a  time  the  Bame 
restraint  i-;  experienced  in  the  formation  of  lines.  The  disease  appears 
to  be  rare  in  this  country,  which — as,  according  to  M.  Onimus,  the  M 
machine  La  especially  apt  (o  induce  it — is  somewhat  remarkable. 

In  several  of  my  cases  there  have  been  symptoms  indicative  of  dis- 
order of  the  centra]  nervous  system.  These  have  consisted  of  headache, 
pain  in  the  back,  and  occasional  tremors  of  the  limbs.  In  one 
Mure  is  marked  inability  to  coordinate  the  muscles  of  articulation  so 
i  sp<  ak  clearly.  The  trouble  seems  to  be  more  in  the  lips  than  in 
(lie  tongue,  and  there  La  decided  mental  impairment.  In  this  case 
there  is  no  doubt  that  (he  affection  has  originated  from  the  excessive 

of  the  muscles  of  the  right  hand  and  arm  in  writing. 

Causes. — Tin  is  more  «- 1 j . t  to  attack  persons  somewhat  ad 

vaneed   in   life,  than  the  very  young,      All  my  patients  were  over  forty 
1  (,'  i    ttt   '/  lit  "  |  JY5, 


788  CEREBRO-SFIXAL  DISEASES. 

years  of  age.  All  were  males,  though  this  proclivity  of  men  to  the  af- 
fection is  not  absolute,  as  several  cases  are  on  record  in  which  women, 
seamstresses  especially,  have  been  its  subjects.  It  is  apparently  some- 
times induced  by  using  the  fingers  in  constrained  positions.  In  one  of 
my  cases,  the  patient,  who  had  been  in  the  habit  of  writing  with  the 
hand  supported  by  the  little  finger,  cured  himself  by  allowing  the  whole 
hand  to  rest  on  the  desk.  The  principal  cause — the  habitual  perform- 
ance of  certain  restricted  movements — has  already  been  sufficiently  con- 
sidered. 

The  opinion  which  Poore  expresses,  that  it  is  due  in  writers  to  the 
use  of  steel-pens,  is  not  borne  out  by  my- experience.  I  have  seen  it  in 
persons  who  always  wrote  with  quill-pens,  and,  as  we  know,  the  disease 
occurs  in  individuals  from  other  causes  than  writing. 

Diagnosis. — Attention  paid  to  the  characteristic  symptoms  of  ana- 
peiratic  paralysis,  and  inquiry  into  the  clinical  history,  wiy  prevent  its 
being  mistaken  for  lead-paralysis,  progressive  muscular  atrophy,  or  any 
other  disease. 

Prognosis. — In  the  early  stage  anapeiratic  paralysis,  by  whatever 
cause  induced,  admits  of  cure.  When  it  has  existed  a  long  time,  and 
when  the  patient  cannot  rest,  a  cure  is  almost  impossible. 

A  majority  of  the  cases  that  have  come  under  my  notice  had  lasted 
too  long  to  admit  of  cure,  and  the  patients  had,  notwithstanding  the 
impei'fections  of  their  work,  persisted  in  using  the  affected  muscles  in 
the  actions  which  had  led  to  the  causation  of  the  disease,  and  then  when 
this  was  no  longer  possible  had  used  the  other  hand  in  like  manner,  till 
it  also  had  become  affected.  In  such  cases  permanent  cures  are  almost 
out  of  the  question,  although  relief  can  be  obtained  to  such  an  extent 
as  to  allow  of  occasional  writing:. 

Morbid  Anatomy  and  Pathology. — As  regards  the  morbid  anatomy, 
there  are  no  data,  and  the  lesion  is  probably  not  one  which  can  be  de- 
tected by  our  present  means  of  observation.  The  affection  is,  however, 
doubtless  due  to  disorder  in  the  normal  action  of  the  motor  cells,  and 
this  disorder  is  the  result  of  over-exertion  of  a  particular  set  of  muscles 
in  a  particular  wray.  Examples  of  cerebral  exhaustion  by  the  predomi- 
nance of  one  idea,  or  a  series  of  ideas  for  a  long  time,  are  often  wit- 
nessed. Writer's  spasm  is,  I  conceive,  the  result  of  a  similar  action  in 
spinal  motor  cells  and  cerebral  nerve  motor  centres. 

Poore,  however,  does  not  believe  that  the  affection,  as  met  with  in 
writers,  can  be  of  central  origin,  but  certainly  the  symptoms  are  of  a 
character  to  militate  against  his  view.  He  has  looked  at  the  disease 
from  too  restricted  a  stand-point.  No  one  can  read  the  report  of  Dr. 
Frank  Smith's  cases  without  at  once  perceiving  that  they  are  the  re- 
sults of  central  lesions. 

Treatment. — The  most  indispensable  means  of  cure  is  rest,  and,  un- 
less this  can  be  secured,  it  is  useless  for  the  physician  to  undertake  thf 


EXOPHTHALMIC   GOITRE.  7>0 

treatment.  In  some  cases  it  has  succeeded  without  any  aspistance. 
The  abstinence  from  the  labor  causing  the  disease,  and  sometimes  from 
all  continuous  muscular  exertion,  should  be  absolute  during  at  least  six 
months. 

The  constant  galvanic  current  has  proved  the  most  effectual  agent 
in  my  hands:  I  apply  it  to  the  sympathetic  nerve,  the  spinal  cord  in  its 
upper  part,  and  to  all  the  muscles  and  nerves  of  the  upper  extremity. 
A  half  an  hour  three  times  a  week,  with  a  current  of  considerable  inten- 
sity (forty  cells),  will  be  sufficient.  Faradization,  in  my  experience,  is 
more  productive  of  harm  than  benefit. 

With  the  galvanism  I  have  administered  the  combination  of  phos- 
phide of  zinc,  and  extract  of  nux-vomica,  recommended  on  page  68  of 
this  treatise. 

The  bromide  of  zinc  in  incipient  cases  is  a  most  efficacious  agent  in 
restoring  tone  to  the  nervous  system,  and  in  conjunction  with  rest  will 
often  effect  a  cure.  It  should  be  used  in  gradually-increasing  doses  as 
recommended  for  convulsive  tremor  and  chorea. 

When  a  cure  cannot  be  effected,  well-devised  prothetic  apparatus 
will  enable  the  patient  to  write  or  perform  other  actions  requiring  skill 
rather  than  strength;  but  I  am  not  sure  that  they  do  not  lead  to  the 
further  extension  of  the  disease,  especially  in  its  cerebral  relations. 
Division  of  tendons  or  muscles  is  not  admissible. 


CHAPTER  X. 

EXOPHTHALMIC   GOITRE. 

It  is  with  hesitation  that  I  have  ventured  to  include  the  remarkable 
disorder  called  Gravi  s's  disease,  Basedow's  disease,  exophthalmic  goitre, 
and  by  several  other  designations,  under  the  head  of  cerebrospinal 
affections.  But,  after  a  careful  consideration  of  all  the  points  in  its 
clinical  history  and  morbid  anatomy,  as  they  have  been  observed  by 
others,  and  Btudied  by  myself,  I  find  it  difficult  to  place  it  in  any  other 
gory.  The  reasons  which  have  governed  me  in  this  decision  will  be 
stated  under  another  division  of  this  chapter. 

Symptoms. — The  first  phenomenon  to  make  its  appearance,  in  a  case 

cophthalmic  goitre,  is  irregular  and  excessive  action  of  the  heart. 

The  <  rgan  is  Ear  more  irritable  than  when  in  a  state  of  health,  and  thus 

slighl  emotional  disturbance  or  moderate  physical  exertion  readily  affects 

ction.     Even  when  the  patienl  is  mentally  and  physically  quiet,  the 

ttions  are  rarely  below  a  hundred  in  a  minute,  and  the  hast  excite- 

tnent,  mental  or  bodily,  will    send    them    lip    tO    a    hundred    and    twenty. 

a  hundred  and  f.ftv.  a  hundred  and  sixty,  or  more,  in  extreme  oas< 


790  CEREBRO-SPIXAL   DISEASES. 

With  the  Increase  in  frequency  there  is  generally  an  augmentation 
of  the  force  of  the  heart.  The  patient  feels  its  pulsations  against  the 
wall  of  the  chest,  feels  thern  as  the  whole  body  is  shaken  by  them,  and 
hears  them  in  the  murmur  which  is  constantly  in  the  ears. 

The  carotids  and  abdominal  aorta  can  be  seen  to  have  their  action 
increased,  and  the  jugular  veins,  always  dilated,  are  sometimes  the  seat 
of  pulsation. 

Physical  examination  does  not  in  general  indicate  the  existence  of 
any  organic  disorder.  Sometimes,  however,  the  heart  is  found  to  be 
enlarged,  but  rather  #s  a  consequence  than  a  cause  of  the  disturbance. 

A  systolic  murmur  is  often  heard,  which  may  be  either  arterial  or 
ventricular.  In  the  former  instance  it  is  .ansemic,  in  the  latter  it  is  due 
to  a  relative  insufficiency  of  the  auriculo-ventricular  valves. 

The  next  symptom  in  order  is  usually  an  enlargement  of  the  thyreoid 
gland,  an  enlargement  which  is  variable,  and  which  is  greater  or  less  in 
accordance  with  the  excessive  or  moderate  action  of  the  heart.  Not- 
withstanding this  capacity  for  change  in  size,  there  is  a  permanent 
augmentation  in  the  volume  of  the  body,  below  which  the  decrease 
does  not  take  place. 

If  the  hand  be  laid  over  the  swollen  thyreoid,  a  peculiar  sensation 
like  that  derived  from  stroking  a  purring  cat — fremissement  cataire — 
is  felt  with  ever)-  systole  of  the  heart,  and  a  bellows-murmur  is  heard 
when  the  ear  is  applied  to  the  part. 

Next,  the  third  essential  phenomenon  makes  its  appearance,  and 
this  consists  of  a  prominence  of  the  eyeballs.  Usually  this  is  sym- 
metrical, but  occasionally  one  protrudes  more  than  the  other.  In 
the  early  stage  of  the  affection  the  lids  can  be  closed  over  the  eyes, 
but  in  extreme  cases  they  cannot  be  brought  together,  and  the  con- 
junctivae  are  therefore  exposed  to  the  atmosphere  and  to  particles 
of  dust,  which  cause  excessive  lachrymation  and  sometimes  trouble- 
some inflammation. 

The  pupils  rarely  exhibit  any  deviation  from  the  healthy  state.  I 
have  sometimes  found  them  abnormally  dilated,  never  contracted,  and 
always  sensitive  to  light. 

A  fourth  and  very  important  symptom  has  recently  been  observed 
by  my  assistant,  Dr.  Louise  Fiske-Bryson,  in  her  careful  study  of  my 
cases  at  the  Post-Graduate  Medical  School.  It  has  never  been  spoken 
of  before,  as  far  as  I  can  ascertain,  and  is  of  the  greatest  importance 
in  regard  to  the  prognosis  of  the  disease.  The  symptom  in  question 
consists  of  a  gradual  and  steady  decline  in  the  extent  of  the  expansion 
of  the  chest  on  forced  inspiration.  In  every  case  that  I  have  examined 
since  Dr.  Bryson's  discovery  this  deficiency  has  been  observed.  In 
well-advanced  cases  the  expansion  is  only  half  an  inch,  and  even  less 
than  that.  When  the  expansion  is  less  than  half  an  inch,  the  prog- 
nosis is  grave. 


EXOPHTHALMIC   GOITRE.  791 

Graefe1  has  called  attention  to  a  circumstance  which  accompanies 
the  protrusion  of  the  eyeballs,  and  that  is  the  disassociation  of  the 
movements  of  the  upper  eyelid  from  those  of  the  eyes.  In  the  nor- 
mal condition,  when  the  globe  of  the  eye  is  raised,  the  lid  is  also  ele- 
vated, and  when  the  globe  is  depressed  the  lid  likewise  falls.  In  ex- 
ophthalmic goitre  these  automatic  movements  do  not  take  place. 

Stellweg  has  called  attention  to  the  fact  that  in  some  cases  there  is 
a  retraction  of  the  eyelid,  sometimes  on  one  side,  sometimes  on  both. 

These  four  phenomena — excessive  action  of  the  heart,  enlargement 
of  the  thyreoid  gland,  protrusion  of  the  eyeballs,  and  inability  to  ex- 
pand the  chest  on  forced  inspiration — may  be  said  to  constitute  the 
cardinal  symptoms  of  the  disease,  but  there  arc  cases  in  which  the 
goitre  is  scarcely  if  at  all  present,  and  others  in  which  the  exophthalmos 
is  absent,  and  probably  others,  again,  in  which  both  these  phenemena 
are  wanting. 

Again,  there  is  no  definite  relation  between  the  degrees  of  severity 
characterizing  these  symptoms.  Sometimes  the  heart  is  most  tumultu- 
ons  in  its  action,  the  goitre  large,  and  the  eyes  very  slightly  prominent, 
or  the  eyeballs  may  protrude  to  the  utmost  and  the  goitre  be  small, 
and  the  heart  not  excessively  deranged,  and  so  on. 

But  though  these  four  phenomena  constitute  the  most  marked  feat- 
ares  of  the  disease,  there  are  others  which,  though  not  so  obvious  to 
others,  add  greatly  to  the  distress  of  the  patient.  Thus  there  are  gen- 
erally tremor,  cough,  nausea,  oedema  of  the  extremities,  increase  of 
temperature,  profuse  sweating,  and  occasional  hemorrhages  from  the 
nose,  lungs,  or  bowels. 

In  two  instances  I  have  observed  constriction  of  the  visual  field 
and  of  the  color  field. 

The  enioi  ional  excitability  I  have  always  found  increased,  sleep  ia  dis- 
turbed ami  insufficient,  there  are  headache,  vertigo,  and  noises  in  the 
.  the  character  often  undergoes  a  marked  change,  and  individuals 
who  were  quiet  ami  gentle  become  excited,  suspicious,  and  irritable. 

Quite  recently  Dr.  Bulkley,1  of  this  city,  has  reported  two  cases  in 
which  there  was  urticaria. 

AnsBmia  i-  generally  tic  predominant  physical  condition,  and  with 
it  there  is  more  or  less  mental  weakness.  The  body  is  usually  much 
emaciated,  probably  in  part  from  defective  appetite  and  defective  as- 
similative power,  which  ordinarily  exist.  In  woman,  t  he  menstrual 
discharge  is  almost  always  either  entirely  suppressed  or  greatly  dimin- 
ished, and  there  is  often  profuse  Leucorrhoea. 

It   rarely  happens  that  there  are  any  marked  disturbances  of  vision, 

1  "  BemerkungcD  Bber  Exophthalmos  mil  Stroma  and  Berzleiden,"  Archiv  ftlr  Oph- 
thalmologic, ' 

'"Two  i  Exophthalmic  Goitre  associated  with  Chronic  Urticaria, 

•  >/'  Nervow and  Mental  DitMtet  October,  is7'>,  p.  ">i"'. 


792 


CEREBRO-SPIXAL   DISEASES. 


and  the  movements  of  the  eyeball  Jo  not  appear  to  be  impeded.  The 
fundus  of  the  eye,  when  examined  with  the  ophthalmoscope,  is  gener- 
ally found  to  be  normal ;  occasionally  there  are  venous  dilatation  and 
pulsation. 

The  pulse,  the  respiration,  and  the  heart  are  exceedingly  erratic. 
In  a  series  of  tracings,  made  for  me  by  Dr.  Mary  Putnam  Jacobi, 
these  facts  were  satisfactorily  demonstrated.  Eight  consecutive  pulse 
tracings,  taken  from  the  same  individual,  showed  every  variation  be- 
tween a  normal  tracing  and  an  modulatory  line.  Great  variations 
were  also  observed  in  the  respiration  tracings  and  in  the  cardigrams. 

For  the  following  history  of  a  case  of  exophthalmic  goitre,  and  the 
accompanying  illustration  from  a  photograph,  I  am  indebted  to  Dr.  J. 
F>.  Crawford,  of  Wilkesbarre,  Pa.  The  case  is  particularly  interesting 
from  the  fact  that  it  occurred  in  a  man,  was  remarkably  acute  in  char- 
acter, terminated  fatally,  and  that,  notwithstanding  the  excessive  action 
of  the  heart  during  life,  there  was  no  cardiac  hypertrophy. 

"July  2,  1872. — Visited  Colonel  E.  13.  H.,  occupation,  lawyer,  fifty- 
three  years  of  age,  and  of  nervo-sanguine  temperament.  Has  been 
afflicted  with  muscular  rheumatism  for  ten  years,  contracted  in  military 
service  in  Virginia,  in  1861  and  1862.  Has  been  engaged  in  active 
business  until  within  the  past  two  weeks.  He  has  at  times  been  con- 
scious of  rapid  and  forcible  beating  of  the  heart,  increased  by  either 
physical  or  mental  effort.     During  the  past  two  months  this  has  been 

steadily  increasing  in  sever- 
ity. He  has  had  much  pain 
in  the  abdomen  for  a  long 
time.  Has  had  a  slight  cough 
and  expectoration  for  more 
than  a  year. 

"About  six  weeks  ago  he 
first  observed  a  distinct  en- 
largement of  the  thyreoid 
gland.  He  remembered,  how- 
ever, that  during  the  past 
year  or  more  he  has  had  dif- 
ficulty in  buttoning  his  shirt- 
collar. 

"The  gland  is  now  two 
and  a  half  inches  in  diameter, 
and  very  prominent.  He  has 
marked  prominence  of  the 
eyes,  giving  to  his  features  a 
staring,  wild  expression  (Fig. 
115).  The  eyeballs  seem  projected  directly  forward.  There  is  no 
strabismus,  nor  perversion  of  sight.     The  eyelids  are  scarcely  sufti- 


Fig.  115. 


EXOPHTHALMIC   GOITRE.  793 

cient  to  cover  the  eyeballs.  Slight  compression  returns  the  eyes  to 
their  normal  position  in  their  sockets  ;  but  upon  removal  of  pressure 
they  are  immediately  protruded  to  the  extent  of  their  former  promi- 
nence. The  lachrymal  secretion  is  as  free  as  usual.  The  action  of 
the  heart  is  exceedingly  violent,  its  heating  being  distinctly  observ- 
able by  the  movements  of  the  patient's  clothing,  and  numbering  L23 
per  minute. 

"  Examination  by  percussion  and  with  the  stethoscope  discloses  no 
symptoms  of  hypertrophy  nor  evidence  of  valvular  lesion.  Area  of  pre- 
cordial dullness  not  increased.  Distinct  bellows-murmur  is  heard  over 
the  left  ventricle — much  more  distinct  over  the  arch  of  the  aorta  and 
left  carotid.  Fine  venous  murmur  is  heard  over  both  thyreoids,  and 
distinct  arterial  impulse  observed  over  abdominal  aorta  on  palpation. 
Breathing  is  vesicular,  respiration  twenty  per  minute.  The  skin  is  pale, 
the  face  becoming  Hushed  when  under  mental  excitement.  The  lips 
and  membrane  lining  the  mouth  exceedingly  pallid.  The  bowels  are 
constipated.  The  patient  has  slept  very  little  during  the  past  four 
months.  He  appears  nervous  and  agitated.  His  hands  are  exceedingly 
tremulous.  He  has  lately  found  it  difficult  to  write  legibly  or  to  even 
hold  a  pen. 

"  A  saline  cathartic  was  prescribed — one-sixtieth  grain  of  aconitia, 
to  be  given  every  six  hours.  Diet  to  be  light  and  nutritious.  Quiet, 
mental  and  physical,  was  enjoined. 

"  3c/. — Patient  slept  several  hours  last  night.  Bowels  have  acted 
freely.     He  feels  better.     Pulse,  120  per  minute. 

'•W/. — Has  rested  well.     Pulse,  100.     Treatment  continued. 

"  \t/i. — Pulse,  90  per  minute.  Has  had  short  paroxysms  of  palpita- 
tion, but  no  pain.  His  appetite  is  poor.  Treatment  continued,  with 
addition  of  citrate  of  iron  and  extract  of  gentian. 

"9c7<. — Symptoms  unchanged.  Examination  of  urine  shows  its 
specific  gravity  to  be  1019,  and  strongly  acid.  A  few  small  tube-casts 
are  noticed.  Numerous  small  crystals  of  triple  phosphate,  quantity 
normal.  Aconitia  continued.  Elixir  pyro-phosphate  of  iron  and  cin- 
chona, one  draohm  before  each  meal. 

"]".'///. — Baa  slept  better.  Pulse,  95.  No  recurrence  of  palpitation. 
Appetite  better.  Protrusion  of  eyes  less  conspicuous.  Patient  rode 
out  a  short  distance  to-day. 

•'l.v//. — Pulse,  LOO.  Condition  nearly  same  as  before.  Tempera- 
ture, 98°  Fahr.     Exophthalmia  less  marked.     Gradual  emaciation. 

"  17^— Consultation  with  Dr.  C.  Washburn.  Patient's  condition 
unchanged.     Treatment  continued. 

"SOtA.  —  fn    consultation    with  I  )rs.   W'ashl  .urn  and  Efothrook,  it  was 

decided  to  give   the  following:    k.  Spir.  Beth,  oo.,   z  \\  ;  hydrocyanic 
add,  "  j.     M.     Sig.  Ateaspoonful  every  six  hours.     Aboul  midnight, 

soon  after  taking  the  second  dose,  the  patient  hecame  delirious.     Hi.- 


794  CEREBRO-SPINAL   DISEASES. 

son,  Dr.  O.  F.  Harvey,  who  was  with  him  at  the  time,  states  that  the 
patient's  face  became  flushed,  his  head  hot,  his  feet  and  hands  cold. 
The  pulse  rose  to  115  per  minute. 

"  Ice-water  was  applied  to  his  head,  and  hot  applications  to  his  ex- 
tremities. Delirium  continued  about  one  hour.  I  was  sent  for,  and 
ordered  the  last-prescribed  medicine  to  be  discontinued.  Aconitia  to 
be  given  as  before,  with  elixir  valerianate  of  ammonia,  one  drachm, 
every  three  hours. 

"  21st. — Patient  able  to  sit  up  and  walk  about  the  room.  Pulse,  95. 
Appetite  improved. 

"  22d. — Symptoms  improved.     Pulse,  90. 

"  31st. — Patient  growing  weaker  ;  otherwise  but  little  changed.  My 
own  ill -health  making  it  necessary  for  me  to  leave  town  for  a  while, 
the  patient  is  left  in  care  of  Dr.  Washburn  until  my  return.  The  fol- 
lowing memoranda  were  made  by  him  : 

"  August  1st. — Patient  about  the  same  as  yesterday.  Resting  very 
poorly. 

"  3d. — Changed  treatment  from  aconite  to  digitalis. 

"  5th. — Not  doing  well  under  treatment  with  digitalis.  Changed 
back  again  to  aconite.  Patient  is  directed  to  take  a  tablespoonful  of 
whiskey  in  a  wineglassful  of  milk  whenever  desired. 

"  1th. — The  whiskey  has  made  patient  feel  more  comfortable. 

"  9th. — No  marked  change.     Patient  seems  to  be  at  a  stand-still. 

"  11th. — Patient  very  much  emaciated  and  weaker  ;  is  scarcely  able 
Lo  expectorate  the  considerable  mucous  secretion  which  accumulates 
about  the  trachea  and  throat 

"  13th. — Milk  and  whiskey  are  the  only  food  which  the  patient's 
stomach  will  retain  ;  to  be  given  freely. 

"  15th. — Returned  home  to-day,  and  again  took  charge  of  patient. 
Emaciation  has  increased.  He  is  much  weaker  than  when  I  last  saw 
him,  otherwise  but  little  changed.  He  takes  no  food  except  a  little 
milk  and  whiskey,  and  sleeps  very  little,  and  that,  he  says,  gives  him 
no  rest,  and  does  not  refresh  him.  The  pulse  is  variable,  ranging  from 
90  to  100  per  minute. 

"  16th. — Has  had  an  attack  of  severe  pain  in  the  left  side  of  chest. 
Chloroform-liniment  to  be  applied.  One-sixth  grain  of  sulphate  of 
morphia  to  be  given  every  three  hours  until  relieved. 

"11th. — Patient  feels  easier.     Debility  increased. 

"20th.  10  A.  M. — Patient  has  great  difficulty  of  breathing  in  the 
recumbent  position.  Extremities  cold.  Pulse  imperceptible  at  the 
wrist.     Died  at  1.30  P.  M. 

"22d.  Post  mortem. — Rigor  mortis  well  marked.  The  eyeballs 
and  thyroid  gland  exhibit  but  little  of  their  former  prominence.  Lungs 
healthy,  except  some  old  adhesions  on  left  side  ;  a  moderate  amount  of 
effusion  in  left  pleura  ;  liver  healthy  ;  gall-bladder  very  small  ;  stom- 


EXOPHTHALMIC   GOITRE.  795 

ach,  spleen,  and  intestines  healthy ;  heart  healthy  in  appearance. 
somewhat  below  the  average  size,  valves  perfect ;  aorta  greatly  en- 
larged through  its  whole  extent,  its  calibre  being  one  and  a  half  inch 
in  diameter;  arteries  generally  enlarged  (or  dilated)  ;  kidneys  moder- 
ately hypertrophied,  and  much  congested  ;  thyreoid  gland  much  en- 
larged and  apparently  normal  in  texture.  General  emaciation  ex- 
treme.    Nervous  system  not  examined."' 

Causes. — Exophthalmic  goitre  is  far  more  frequent  in  women  than 
in  men.  Of  the  great  number  of  cases  occurring  in  my  experience, 
very  t'rw  were  in  men.  Euleiiburg1  states  the  relation  of  women 
to  men   as  two  to  one.      Romberg  and   llennock,2   of  twenty-seven 

■-,  found  twenty-four  in  females,  and  Cheadle,3  but  one  male  in 
nine  cases. 

The  disease  is  more  frequent  between  the  ages  of  twenty  and  forty 
than  at  any  other  period.  All  my  cases  were  within  these  limits.  In- 
stances, however,  have  been  reported  occurring  both  in  younger  and 
older  persons.  Men  are  stated  by  Jaccoud  to  be  more  frequently 
affected  after  thirty  years  of  age,  and  women  under  this  age. 

Among  the  exciting  causes  mental  shock  is  probably  the  most  effi- 
cient. Four  of  my  cases  originated  from  this  influence.  It  has  been 
known  to  be  developed  almost  instantaneously  by  powerful  emotional 
disturbance. 

Dr.  Begbie*  has  reported  a  case  in  which  the  disease  was  ap- 
parently caused   by  a  wound  of  the  head,  ami  Graefe  has  adduced  a 

like   example. 

Diagnosis, — There  is  not  much  danger  that  exophthalmic  goitre 
will  be  mistaken  for  any  other  affection  by  a  physician  familiar  with 
its  very  pronounced  characteristics.  The  excessive  action  of  the  heart, 
the  enlargement  of  the  thyreoid  gland,  the  prominence  of  the  eyeballs, 
the  inability  to  expand  the  chest,  the  amende  condition  of  the  system. 

the    venous    murmurs,   all    go    to    make    up   a    pathological    picture,   of 

which  the  elements  are  sufficiently  well  marked.  Hut  there  are  some- 
times cases  of  the  disease  mel  with  in  which  some  of  the  phenomena 
are  nol  very  decidedly  shown,  and,  in  these,  care  should  be  exercised 

before  a  definite  opinion  is  pronounced.      The  facts  that  there   are   not 

the  physical  Bigns  of  organic  lesion  of  the  heart,  notwithstanding  it- 
excessive  action,  that  the  swelling  of  the  thyreoid  communicates  a  pe- 
culiar thrill  to  the  hand,  and   that    the   protrusion  id"  the  eyeballs  is  on 
both  sides  and  is  unaccompanied  with  disturbance  of  vision,  will  • 
in  doubtful  cases  Berve  to  render  the  diagnosis  Bure. 

1  "Die  Basedow'schc  Krankhdt,"  Ziemssen'q  u Handbucb,"  n.  8.  w.,  twSlf ter  Band, 
II..  zw.  it,-  Balfte,  Leipzig,  1875,  p.  7.">. 

oberg, "  Klinische  Wahrneroungen  and  Beobachtungen,"  Berlin,  1861, 
lophthalmic  Goitre,"  "  St.  George's  Hospital  R      »rts,"  rol.lv.,  1869,  p.  116. 
1  Edinburgh  M  M9. 


700  CEREBRO-SPINAL   DISEASES. 

Prognosis. — It  is  not  often  the  case  that  exophthalmic  goitre  proves 
fatal.  A  few  such  cases  are,  however,  on  record,  and  thei'efore  the 
prognosis,  even  as  regards  life  and  death,  should  he  somewhat  guarded. 
The  expansion  of  the  chest  is  an  important  factor  in  the  prognosis. 
Dr.  Bryson  states  that  when  the  chest  expansion  is  less  than  half  an 
inch  the  case  terminates  fatally.  I  have  seen  this  statement  veri- 
fied in  one  case.  Relative  to  a  cure  being  effected,  there  is  still  more 
uncertainty,  though  I  am  inclined  to  think  that  with  proper  treatment 
exophthalmic  goitre  is  not  a  very  intractable  affection;  the  prospect 
of  a  mitigation  of  the  severity  of  the  phenomena  may  be  reasonably 
held  out  in  almost  every  case.  Of  the  eleven  cases  occurring  in  my 
experience,  four  were  permanently  cured,  and  six  more  or  less  com- 
pletely benefited.  One  only,  a  young  lady  from  Astoria,  and  the  most 
extreme  instance  of  the  disease  I  have  witnessed,  resisted  all  treatment. 

Morbid  Anatomy  and  Pathology. — Lesions  have  been  found  in  the 
brain,  the  spinal  cord,  and  the  sympathetic  nervous  system,  and  in  other 
cases  there  have  been  no  appreciable  alterations  discovered  in  any  one 
of  these  centres.  The  opinion  prevailed  at  one  time  that  the  seat  of 
the  disease  was  in  the  sympathetic  nerve,  especially  the  cervical  por- 
tion, and  several  instances  in  which  this  part  of  the  nervous  system 
was  the  seat  of  morbid  process  have  been  reported  by  Traube  and 
Recklinghausen,1  Trousseau  and  Peter,2  Archibald,3  and  others. 

The  changes  observed  in  the  sympathetic  ganglia  are  enlargement, 
hardness  and  redness,  granular  degeneration,  infiltration  with  round 
cells  or  with  spindle-shaped  cells,  destruction  of  the  ganglionic  struct- 
ure with  increase  in  the  amount  of  connective  tissue.  Physiological 
experiments  on  the  sympathetic  nerve  also  prove  conclusively  that  the 
symptoms  of  exophthalmic  goitre  can  be  produced  artificially  by  this 
means. 

The  arguments  against  this  theory  are  certainly  very  convincing. 
A  number  of  cases  are  recorded  where  no  changes  can  be  discovered  in 
either  the  sympathetic  nerve  or  its  ganglia.  Paul,4  and  Founder  and 
Ollivier,5  have  given  the  details  of  post-mortem  examinations  made  in 
two  cases  of  the  disease  in  question,  in  which  the  sympathetic  and  all 
its  ganglia  were  in  a  normal  condition.  Ilammar,0  in  a  report  of  a 
case  of  his  own  where  no  lesion  of  the  sympathetic  could  be  discov- 
ered, cites  twenty-two  other  cases  where  autopsies  were  obtained.  Of 
these,  seven  showed  lesions  in  the  sympathetic  system,  while  in  the 
fifteen   remaining  no   sympathetic  lesion  could  be  discovered  at  all. 

1  "Deutsche  Klinik,"  1863. 
-  Gazette  Hebdomadaire,  1864. 

3  Medical  Times  and  Gazette,  1865. 

4  Berliner  klin.  Wochenschrift\  1865. 

6  Gazeltt  Hebdomadaire,  isfiV;  and  Union  Medicate,  1868. 
6  Up8ala  Lakare  Forh&nde,  vol.  xxiv. 


EXOPHTHALMIC  GOITRE.  797 

Two  other  autopsies  have  heen  reported  since  thou,1  one  by  Ro 
velt  and  one  by  W.  Hale  White,  in  neither  of  which  were  the  sympa- 
thetic nerves  diseased.  As  to  the  physiological  experiments,  thongh 
it  is  admitted  that  many  of  the  individual  symptoms — such  as  dilata- 
tion of  blood- vessels,  exophthalmia,  enlargement  <>t'  the  thyreoid  gland, 
contraction  of  the  lids,  and  accelerated  action  of  the  heart — can  readily 
be  obtained  by  producing  artificial  lesions  of  the  sympathetic,  it  is  well 
known  that  anyone  such  lesion  cannot  result  in  all  of  these  Bymptoms, 
Borne  of  them  :  re  produced  by  paralysis  and  others  by  irritation 
of  the  sympathetic.  I  think  it  will  he  admitted  that  it  is  clearly  im- 
possible for  any  one  lesion  to  produce  both  irritation  and  paralysis  at 
the  same  time. 

I  am,  therefore,  inclined  to  think  that  in  the  presenl  state  of  our 
knowledge  we  .ire  scarcely  warranted  in  locating  exophthalmic  goitre 
in  the  sympathetic  nervous  system. 

The  theory  of  a  central  lesion  is  far  more  acceptable  to  my  mind. 
In  the  first  place,  centres  are  known  to  exist  grouped  together  within 
a  small  area  in  the  medulla,  lesions  of  which  result  in  the  appearance 
of  the  three  principal  symptoms  of  the  disease. 

Filehne,  in  hia  now  well-known  experiments,  produced  each  of  the 
three   symptoms   in   turn,  and  in  one  case  nil  three  of  them  together — 
ilt  which  has  never  heen  obtained  by  any  single  lesion  made  on 
the  sympathetic.     Probably  the  fourth  symptom — Dr.  Bryson's  symp- 
tom—  was  obtained   also  by  Filehne,  although,  not   knowing  of  its  ex- 
;e,  he  probably  did  not  look  for  it. 

In  the  second  place,  it  does  not  Beem  unreasonable  to  attribute  the 
three  principal  conditions  of  vagus  paralysis,  vaso-raotor paralysis, and 
respiratory  paralysis — which  produce  the  four  principal  symptoms, 
accelerated  hearl  action,  enlargement  of  the  thyreoid  gland,  exoph- 
thalmia, and  diminished  chesl  expansion  —  to  a  single  circumscribed 
11  affecting  the  vague  nucleus,  the  vaso-motor  nucleus,  and  the 
respiratory  nucleus.  Polyuria,  which  is  a  frequent  symptom  of  Gra1 
disease,  can  also  he  produced  by  a  lesion  in  this  region. 

Physiological  research  is  not  unsupported  by  post-mortem  evidence. 
Dr.  YV.  Hah-  White-'  has  reported  a  case  where  ••the  sympathetic  \\a> 
found  to  I,.-  healthy.  A  series  of  sections  were  made  from  the  f. 
part  of  the  medulla  to  the  corpora  quadrigemina.  At  the  level  of  the 
[owesl  part  of  the  olivary  nucleus  there  was,  just  under  the  posterior 
of  the  medulla,  evidence  of  siiuri,t  inflammation.  The  ijexl 
few  sections  were  quite  healthy,  but  th<>se  in  the  neighborhood  of  the 
bowed  considerable  changes.  Immediately  under  the 
posterior  surface  of  the  medulla,  extending  from  the  mesial  line  as  far 

•  if. , i  m    bodies,  which  were   slightly  implicated,  were   1111- 

'   \fedieal  Record,  March  81,  1689;  Bi  I  Journal,  March  80, 

'•'  Op 


798  CEREBRO-SPINAL   DISEASES. 

raerous  haemorrhages.  The  area  occupied  by  these  hemorrhages  did 
not  extend  deeply,  so  that,  except  for  a  slight  implication  of  the  nerve- 
cells  of  the  sixth  nucleus  on  one  side,  the  nerve-cells  had  escaped  in- 
jury. The  haemorrhages  seemed  almost  entirely  limited  to  the  pos- 
terior part  of  the  format io  reticularis,  but  there  were  two  or  three 
small,  dec])  ones.  They  were  not  marked  at  this  level,  but  were  ob- 
served up  to  the  lower  part  of  the  aqueduct  of  Sylvius."' 

Dr.  White  believes  this  is  the  first  case  where  organic  lesions  have 
been  discovered  in  the  medulla  in  exophthalmic  goitre,  but  Lockhart 
Clark1  reports  a  case  where  the  "corpora  quadrigemina  and  the  me- 
dulla, particularly  on  its  posterior  pai-t,  were  very  soft,  and,  on  minute 
examination,  displayed  the  usual  appearance  of  common  softening." 

Fox2  states  that  "the  weak  point  in  this  theory  of  central  origin 
seems  to  be  that  there  is  so  seldom  any  dilatation  of  other  vessels  be- 
sides the  thyreoidal."  There  is  a  strong  probability  that  there  is  a 
general  dilatation  of  the  blood-vessels.  It  has  been  conclusively  shown 
that  in  exophthalmic  goitre  the  electrical  resistance  of  the  patient  is 
very  much  diminished  below  the  normal  point.  And  although  as  yet 
there  is  no  absolute  proof,  it  seems  plausible  and  probable  that  a  gen- 
eral dilated  condition  of  the  vessels  would  account  for  the  greatly 
diminished  electrical  resistance. 

In  many  instances  no  lesion  has  been  discovered  at  all,  and  the 
burden  of  proof  goes  to  show  that  exophthalmic  goitre  is  frequently  a 
reflex  neurosis.  It  is  not  essential  that  even  the  fatal  cases  should  be 
of  organic  origin,  as  a  reflex  irritation  can  readily  be  imagined  to  be 
of  so  powerful  a  nature  as  to  produce  almost  total  paralysis  of  the 
nerve-cells  in  the  medulla,  which,  of  course,  in  the  present  state  of  our 
knowledge,  would  be  undetected  after  death.  The  theory  that  ex- 
ophthalmic goitre  is  often  of  reflex  origin  is  supported  by  clinical  evi- 
dence. Semon8  reports  a  case  on  which  he  operated  by  means  of  the 
galvano-caustic  loop  for  the  removal  of  multiple  recurrent  mucous 
polypi  of  the  nose.  Within  a  day  or  two  after  the  operation  exoph- 
thalmia  of  the  right  eye  suddenly  appeared.  Graefe's  and  Stellweg's 
symptoms  were  both  present,  but  there  was  no  enlargement  of  the 
thyreoid  gland  and  no  increased  action  of  the  heart.  Hoffmann,  of 
Cologne,4  reports  a  case  of  exophthalmic  goitre  which  was  entirely 
cured  by  an  operation  performed  within  the  nasal  cavity,  and  Hack,  of 
Freiberg,  and  B.  Frankel,  of  Berlin,  both  report  cases  where  operations 
for  nasal  diseases  have  cured  cases  of  Graves's  disease.  It  will  not  be 
amiss  to  mention  here  that  Mr.  George  Storkcr,  of  London,  reports  two 
cases  where  ordinary  goitre  disappeared  after  intranasal  operations. 

1  "The  Influence  of  the  Sympathetic  on  Disease,"  E.  Long  Fox. 

2  Fox,  op.  <-if. 

3  Lancet,  London,  1889,  i.,  p.  789. 

4  Berliner  klin.  Wochemehrift,  1888,  xxv.,  850. 


EXOPHTHALMIC   GOITRE.  799 

As  regards  the  morbid  anatomy  of  the  organs  which  are  the  seat 
of  the  more  prominent  symptoms  of  the  disease,  a  few  words  are  n< 
sary.  The  heart  is  sometimes  found  to  be  the  seat  of  structural  dis- 
ease in  cases  of  exophthalmic  goitre,  but  these  Lesions — generally  hy- 
pertrophy and  mitral  insufficiency — are  themselves  rather  the  results 
thin  the  canst',  and  moreover  they  are  not  such  as  could,  so  far  as  our 
knowledge  extends,  produce  either  enlargement  of  the  thyreoid  gland 
or  protrusion  of  the  eyeballs. 

This  enlargement  of  the  thyreoid  is  due  not  to  any  proliferation  of 
its  proper  tissue,  but  entirely  to  the  increased  quantity  of  blood  enter- 
ing its  vessels  and  distending  it  as  water  distends  a  sponge.     The  ves- 
therefore,  are   always   found  enlarged  far  beyond  their  normal 
dimensions. 

The  prominence  of  the  eyeballs  has  been  supposed  to  result  from 
vascular  turgescence  in  the  orbit,  to  an  increase  in  the  amount  of  fat 
which  this  cavity  normally  contains,  and  to  a  fatty  degeneration  of  the 
ocular  muscle-  by  which  their  tone  is  destroyed,  and  the  eyeball  allowed 
to  protrude.  These  causes  probably  contribute  to  the  production  of 
the  phenomenon.  We  must,  however,  add  another  still  more  influen- 
tial, and  that  is  the  contraction  of  Midler's  orbito-ocular muscle  by  which 
action  the  eye  is  actively  thrust  forward. 

Treatment. — The  internal  medication  most  to  be  relied  on  in  my 
rience  is  that  <>l'  which  iron,  some  one  of  the  bromides — zinc  pref- 
erably— digitalis,  and  ergot,  are  the  primary  features.  These  may  be 
combined  as  in  the  following  formula:  1£  Ferri  pyrophosphatis,  zinci 
bromidi,  aa  I  j  ;  digitalis  tinct.,  3  v  ;  crgotae  ext.  fl.,  §  iv  :  M.  ft.  mist. 
I,  a  teaspoonful  three  times  a  day.  In  addition,  the  patient  should 
drink  a  glass  or  two  of  malt  liquor  every  day,  and  eat  plentifully  of 
animal  food. 

Recently  I  have  obtained  such  excellent  results  from  strophanthus 
and  from  the  carbazotate  of  ammonium  that  I  use  these  remedies  to 
the  exclusion  of  all  others,  excepl  such  tonics  as  the  condition  of  the 
patient  seems  t<>  call  for.  Strophanthus  was  tirst  experimented  with 
by  Prof.  T.  R.  Fraser.1  Wood  *  states  that  "the  nam"  Strophanthus 
komb't  has  been  given  to  the  species  which  is  believed  to  yield  the 
kombe  poison,"  bul  "Blondel's*  researches  have  shown  that  such  a 
species  as  Strophanthus  Jeombh  does  nol  exist;  what  has  been  distin- 
guished by  that  name  hitherto  is  simply  Strophanthus  hispidus" 

Experiments  by  Fraser,  Drasche,  and  Zerner  and  Loaw4  show  thai 
strophanthus  prolongs  the  diastole  of  the  heart,  causes  it  to  beat  more 
slowly  and  to  discharge  at  each  contraction  a  larger  quantitj  of  blood 

1  .A"'  \  "1.  \  ii..  p.   111. 

rherapentii  I '       iplea  and  Prncti 

!.  i.,  p.  55. 
Woo  I,  •• 


800  CEREBRO-SriNAL   DISEASES. 

into  the  arterial  system  ;  at  the  same  time  the  arteries  become  con- 
tracted. These  facts  are  clearly  expressed  in  an  able  article  in  the 
Iiriti--</i  Medical  Journal.1 

Bahadhurji,1  who  experimented  with  strophanthus  in  cooperation 
with  Langgaard,  of  Berlin,  found  that  strophantlms  has  a  marked 
central  effect  upon  the  vagus.  They  report  also  that  the  respirations 
are  at  first  increased,  but  are  subsequently  slower  and  weakened.  This 
may  be  the  result  on  the  healthy  organism,  but  in  exophthalmic  goitre, 
at  least  in  the  cases  that  have  come  under  my  observation,  the  respi- 
ration becomes  slower  and  stronger,  while  the  power  of  expansion 
becomes  greater.  It  is  therefore  probable  that  strophantus  affects 
the  central  respiratory  centre  as  well  as  the  vagus  centre.  If  these 
statements  are  true,  we  have  in  strophantlms  a  remedy  which  should 
exert  a  powerful  influence  in  subjugating  the  four  principal  symptoms 
of  exophthalmic  goitre — namely,  the  exophthalmia,  the  enlargement 
of  the  thyreoid,  the  cardiac  rapidity,  the  shortened  respirations,  and 
the  diminished  chest  expansion. 

Zerner  and  Loaw8  have  employed  strophanthus  with  success  in  this 
disease.  Brower4  reports  three  very  interesting  cases  which  were  cured 
by  this  drug  in  from  four  to  six  weeks.  Three  cases  of  my  own  show 
decided  improvement  under  its  use.  Other  observers  have  used  it  with 
advantage,  but  the  foregoing  cases  are  sufficient  to  show  its  practical 
utility  in  many  instances. 

The  only  preparations  of  the  drug  which  can  be  obtained  are  the 
tincture  of  strophanthus  and  strophanthine.  The  latter  is  hardly  avail- 
able for  therapeutic  purposes,  as  its  extreme  potency  renders  its  use 
dangerous.  The  ordinary  dose  of  strophanthine  is  -50V0  °f  a  grain  ; 
that  of  the  tincture  is  from  five  to  eight  drops  in  water  three  times  a  day. 

Carbazotate  of  ammonium  was  first  employed  as  a  remedy  against 
exophthalmic  goitre  by  my  assistant,  Dr.  A.  C.  Combes,  at  the  Post- 
Graduate  Hospital.  Following  the  directions  of  Dr.  Combes,  I  have 
given  the  remedy  in  pill  form  (each  pill  containing  one  grain  of  the 
drug)  three  times  a  day  for  the  first  week.  In  the  second  week  two 
pills  three  times  a  day  are  given,  and,  if  it  can  be  borne,  three  pills 
three  times  a  day  in  the  third  week.  The  physiological  effects  of  the 
drug  are  very  decided.  At  about  the  end  of  the  first  week  the  skin 
and  conjunctivae  assume  a  slight  saffron  color,  which  deepens  if  the 
drug  is  persisted  in.  Then  a  peculiarly  unpleasant  odor  emanates 
from  the  body,  which  is  identical  with  that  produced  by  dirty  feet, 
and  can  be  distinctly  noticed  if  you  approach  within  six  or  eight  feet 
of  the  patient.    Following  this,  severe  gastric  disturbances  show  them- 

1  American  Practitioner,  Louisville,  April  -7,  18S9. 

2  "Ref.  Handbook  of  Medical  Science,"  vol.  vi.,  p.  GG4. 

3  Wien,  meet.  Wochensclirift,  1887.     Wood,  op.  tit. 
1  Journ.  Amcr.  Med.  yissoc,  1889,  xi.,  p.  626.  ■ 


EXOPHTHALMIC   GOITRE.  801 

selves.  It  is  rarely  possible  that  patients  can  take  this  remedy  longer 
than  three  weeks,  but  while  they  take  it  the  effects  upon  the  heart, 
the  respiratory  tract,  and  the  exophthalmia  are  undoubted.  In  view 
of  the  foregoing  statements  the  following  cases  may  not  prove  unin- 
teresting : 

Case  I. — Mrs.  T.  came  to  my  clinic  on  June  19,  1889.  She  is 
forty-five  years  of  age,  and  has  passed  through  a  good  deal  of  worry 
and  trouble.  On  June  19th  her  pulse  was  120.  Goitre  measured  fif- 
teen inches  ;  chest  expansion  was  a  little  over  an  inch.  The  eyes  were 
very  prominent.  She  was  given  the  carbazotate  of  ammonium  in  jiill 
form — one  grain  three  times  a  day  after  meals.  The  second  week  she 
took  two  grains  three  times  a  day,  and  the  third  week  three  grains 
three  times  a  day.  On  July  5th,  sixteen  days  after  treatment,  the 
pulse  was  reduced  to  112;  the  goitre  measured  fourteen  inches;  the 
eyes  were  less  prominent.  On  July  12th,  twenty-three  days  after 
treatment  began,  it  was  found  necessary  to  leave  off  the  carbazotate 
of  ammonium,  as  the  physiological  effects  were  very  decided.  The 
tincture  of  strophanthus  was  then  substituted,  in  doses  of  seven  drops 
three  times  a  day.  On  August  23d  the  goitre  was  thirteen  inches  in 
circumference  ;  pulse,  98  ;  eyes  much  less  prominent.  The  circumfer- 
ence of  the  neck  over  the  goitre  is  now  twelve  inches  and  a  half  ; 
very  little  enlargement  can  be  observed.  The  pulse  is  88 ;  the  chest 
expansion,  two  inches  ;  and  the  prominence  of  the  eyeballs  is  almost 
gone.  She  has  not  taken  strophanthus  or  any  other  remedy  for  ex- 
ophthalmic goitre  for  several  weeks,  yet  there  seems  to  be  no  return 
of  her  symptoms.  No  other  remedies  were  given  at  the  same  time 
with  the  carbazotate  of  ammonium  or  with  the  strophanthus.  Her 
general  health  is  greatly  improved. 

Case  II. — Mrs.  J.  S.,  aged  forty-nine,  consulted  me  on  November 
1,  1889.  llrr  eyes  began  to  protrude  three  years  ago.  Pulse,  120 
and  Intermittent.  The  goitre  was  not  large  ;  its  measurement  through 
its  middle  line  and  over  the  seventh  cervical  vertebra  was  thirteen 
inches  and  five  eighths.  The  eyes  were  very  prominent  and  seemed 
as  if  they  would  drop  from  their  sockets,  she  complained  of  attacks 
of  great  pain  in  the  eyeballs,  lasting  all  day;  it  felt  "as  if  the. 
would  burst."  The  chesl  expansion  was  an  inch  and  a  half.  Neither 
v<>u  Graefe'a  nor  Stellweg's  symptoms  were  present.  She  complained 
of  excessive  thirst,  tremor,  excessive  sweats,  leucorrhcea,  and  a  rash  on 
the  body.  She  had  been  treated  for  diabetes.  She  was  treated  with 
the  carbazotate  of  ammonium,  in  doses  of  one  grain  three  times  a  day. 
On  November  6th  the  pulse  was  reduced  to  100,  and  was  quite  regu- 
lar.    The  oeck  measurement  was  thirteen  inches  and  three  sixteenths, 

Ldction  "!'  nearly  half  an  inch  in  a  week.  She  was  DOW  Under  the 
physiological  effects  Of  the  drug,  BO  her  treatment  was  changed  t«»  the 
tincture   of  strophanthus,  in   doses  of  seven   drops   three  times  a  day. 


802  CEREBRO-SPINAL   DISEASES. 

She  has  intermitted  this  treatment  once  to  go  back  to  the  carbazotate 
of  ammonium  for  a  week,  bat  at  the  expiration  of  that  time  she  re- 
turned to  the  strophanti) us  again. 

On  November  loth  she  said  she  felt  much  better ;  a  marked  dimi- 
nution in  the  protrusion  of  the  right  eye  was  noticed  ;  the  pulse  was 
100 ;  temperature,  995°  ;  neck  same  as  before.  She  has  progressed 
steadily  up  to  the  present  time.  At  the  last  visit  both  eyes  were  de- 
cidedly less  protruded ;  the  neck  measured  only  thirteen  inches  ; 
pulse,  88  ;  chest  expansion,  two  inches  ;  all  other  symptoms  have  dis- 
appeared. 

Case  III. — John  F.,  thirty-two  yearsof  age,  consulted  me  on  May 
4,  1890.  He  first  noticed  protrusion  of  the  eyeballs  five  years  previ- 
ously. At  his  first  examination  his  eyeballs  projected  ten  sixteenths 
of  an  inch  beyond  the  inferior  orbital  ridge.  The  pulse  was  1G0  ; 
chest  expansion,  five  eighths  of  an  inch.  The  neck,  over  the  largest 
part  of  the  goitre,  measured  fifteen  inches.  There  was  also  myopia, 
contraction  of  the  visual  field,  and  contraction  of  the  color  field. 

The  carbazotate  of  ammonium  was  given  in  the  manner  pursued  in 
the  former  cases. 

On  May  18th  the  pulse  was  140 ;  expansion,  one  and  a  quarter 
inches ;  goitre,  fourteen  and  a  quarter  inches.  The  tincture  of  stro- 
phantus, in  seven-drop  doses  three  times  a  day,  was  now  substituted 
in  place  of  the  carbazotate  of  ammonium,  and  was  continued  till  the 
last  part  of  June.  The  pulse  was  then  116;  expansion,  two  inches; 
goitre,  thirteen  and  a  half  inches.  The  patient's  general  condition  was 
excellent,  and  he  returned  to  work. 

Galvanization  of  the  cervical  sympathetic  has  been  advocated,  and 
many  cures  have  been  reported  to  have  resulted  from  the  use  of  this 
remedy  alone.  In  my  hands  it  has  not  been  successful.  Undoubtedly 
galvanization  of  the  sympathetic  will  diminish  the  frequency  of  the 
heart-beat  while  the  application  lasts,  but  it  does  not  seem  to  me  rea- 
sonable or  scientific  to  treat  one  symptom  of  a  disease  and  to  pay  no 
attention  to  the  root  of  the  evil  in  the  medulla.  On  the  other  hand, 
remedies  which  stimulate  the  vagus,  respiratory,  and  vaso-motor  cen- 
tres in  the  medulla  cannot  but  be  attended  by  beneficial  results.  To 
this  end  I  not  only  employ  the  remedies  previously  mentioned,  but 
also  advocate  systematic  muscular  exercise,  which  must,  however,  be 
carried  on  in  a  very  careful  manner.  One  of  my  patients,  who  was 
placed  under  the  care  of  Dr.  Henry  Ling  Taylor,  and  took  a  thorough 
course  under  that  gentleman's  supervision,  recovered  without  any  other 
treatment. 


SECTION    IV. 

DISEASES  OF  THE  PEPJPHEKAL  NERVOUS 

SYSTEM. 


I  do  not  propose  to  include  under  this  head  all  the  diseases  to  which 
the  several  nerves  of  the  body  are  liable.  Many  of  them  are  more  ap- 
propriately considered  in  special  treatises  devoted  to  the  eye  and  ear, 
and  others  differ  merely  in  their  situation,  the  essential  condition  being 
the  same.  Thus  any  nerve  of  the  body  may  be  paralyzed  from  injury, 
a  disease,  or  from  some  contiguous  affection  capable  of  interfering  with 
the  due  performance  of  its  functions.  It  would  scarcely  be  necessary 
in  a  general  treatise  like  the  present  to  give  such  paralyses  sep- 
arate consideration,  as  their  features  and  the  treatment  proper  can 
be  sufficiently  pointed  out  under  the  head  of  a  typical  representa- 
tive. 

Besides,  many  affections  which  are  often  regarded  as  being  located 
in  the  peripheral  nervous  system  are  really  central  in  situation.  Among 
these  are  various  maladies  characterized  by  paralysis,  spasm,  hyperes- 
thesia, and  anaesthesia,  whiob.  have  already  been  considered  as  central 
disea 

1  shall  divide  the  affections  of  the  peripheral  nervous  system  into 
two  groups  ;  those  which  are  characterized  by  recognizable  anatomical 
changes  in  the  nerves — Organic  Diseases;  and  those  in  which  such 
changes  are  oot  discoverable — Functional  Diseases.  The  four  immedi- 
ately following  chapters  describe  known  pathological  conditions,  an  '. 
therefore  organic  diseases;  the  others  relate  to  affections,  or  rat  In  i 
symptoms,  which  arc  sometimes  the  results  of  structural  changes  in  the 
nerves,  and  are  again  apparently  entirely  functional.  In  the  present 
stale   of    our   knowledge   it   appears    to  bo  impossible   to  be   mon 

exact. 


804  DISEASES   OF  THE  PERIPHERAL  NERVOUS  SYSTEM. 

CHAPTER    I. 

NEURAL    CONGESTION. 

Congestion  of  nerves  is,  as  Mitchell '  states,  scarcely  recognizable 
by  clinical  observation.  My  experience  is  limited  entirely  to  a  study  of 
the  phenomena  exhibited  by  the  affection  artificially  produced,  and  in 
these  investigations  I  have  followed  the  line  which  Mitchell  has  so 
thoroughly  pursued. 

If,  as  he  has  pointed  out,  a  nerve-trunk  be  subjected  to  the  action 
of  intense  cold  so  as  to  be  frozen,  the  period  of  congelation  is  immedi- 
ately followed  by  one  of  congestion,  the  result  of  the  paralysis  of  the 
vaso-motor  nerves  of  the  part. 

Thus,  if  the  sciatic  nerve  of  a  rabbit,  for  instance,  be  exposed,  and, 
while  a  thin  sheet  of  India-rubber  protects  it  from  direct  contact,  the 
vapor  of  ether  or  of  rhigolene  be  thrown  upon  it  from  a  vaporizer,  the 
functions  of  the  parts  below — sensation  and  motion — are  abolished,  and 
remain  so  while  the  congelation  lasts. 

But  as  the  temperature  rises  a  new  set  of  phenomena  ensues.  The 
nerve  loses  its  whiteness,  and  becomes  pinkish,  or  even  red,  and  this 
gradually  disappears — without,  so  far  as  can  be  perceived,  the  animal 
suffering  any  marked  inconvenience.  But,  if  the  operation  be  repeated, 
or  if  the  congelation  be  continued  for  a  long  time,  the  nerve  becomes 
permanently  discolored,  and  the  animal  is  rendered  lame.  If  the  nerve 
be  examined  with  a  lens,  such  for  instance  as  one  of  those  furnished 
with  Nachet's  simple  dissecting  microscope,  the  vessels  are  seen  to  be 
enlarged  and  more  numerous  than  in  the  normal  condition,  and  minute 
extravasations  coming  from  the  over-distended  vessels  are  seen  between 
the  fibres. 

In  man,  though  we  cannot  observe  the  anatomical  changes,  we  are 
able  to  study,  subjectively,  with  fullness  and  exactness,  the  symptoms 
which  are  due  to  neural  congestion. 

Mitchell,2  in  reference  to  this  point,  says  :  "I  have  repeatedly  chilled 
or  frozen  the  ulnar  nerve  in  myself  with  ice  or  ice-and-salt.  The  first 
effect  is  to  cause  intense  aching  pain,  which,  although  most  severe  in 
the  little  finger,  the  outside  of  the  third  finger,  and  the  ulnar  palm,  is 
also  felt  in  the  whole  hand,  and  especially  on  the  back  of  the  hand  at 
the  space  between  the  metacarpal  bones  of  the  thumb  and  forefinger. 
The  pain  rather  suddenly  ceases  at  a  certain  stage  of  freezing,  and  for  a 
moment  the  hand  feels  natural.  Then  the  ulnar  distribution  in  the  hand 
begins  to  be  numb,  and  this  increases  till  all  sensibility  is  lost — touch, 
pain,  and  the  thermal  sense  disappearing  in  turn.  Last  of  all,  motility, 
which  very  rarely  is  slightly  affected,  lessens  by  degrees  and  is  lost  alto- 

1  "Injuries  of  Nerves  and  their  Consequences,"  Philadelphia,  1872,  p.  56. 
8  Op.  cit.,  p.  69. 


NEURAL   CONGESTION.  805 

gether.  Soon  after  the  part  grows  numb,  the  thermometer  rises  slowlv, 
sense  of  heat  is  felt  in  the  ulnar  palm,  and  this  region  in  my  own  case 
sweats  excessively.  At  the  same  time  the  ulnar  nerve  at  the  elbow 
grows  very  excitable,  and  the  least  tap  on  the  nerve  causes  slight  pain  in 
the  third  and  fourth  fingers,  and  sudden  flexion  of  the  first  phalanges 
of  all  the  fingers  save  the  first,  as  well  as  adduction  of  the  thumb. 

"  The  average  rise  of  the  thermometer  in  moderate  chilling  which 
does  not  annihilate  sensation,  and  leaves  motion  but  slightly  impaired, 
is  2°  Fahr.  In  more  complete  freezing  it  is  in  my  case  from  3°  to  4° 
Fahr. 

"The  symptoms  which  follow  the  thaw  are,  as  I  believe,  due  chiefly 
to  congestion.  The  nerve  remains  sore  at  the  elbow  and  even  some  dis- 
tance below  and  above  it,  while  the  brachial  plexus  may  become  tender 
(Waller),  and,  as  the  thawing  occurs,  the  heart  maybe  enfeebled  and 
syncope  threaten  (Waller),  or  vertigo  occur,  as  I  have  felt  in  my  own 
case.  The  terminal  distribution  of  the  nerve  suffers,  after  severe  freez- 
ing, for  hours  or  days  ;  the  soreness  of  surface,  numbness,  prickling,  and 
partial  loss  of  power  may  continue,  together  with  a  certain  fullness 
which  is  felt,  and  which  makes  itself  visible  to  the  eye.  Even  after 
slight  freezing  there  may  remain  for  hours  certain  uncomfortable  sen- 
sations, which  scarcely  admit  of  distinct  description.  In  one  instance 
these  symptoms  endured  for  eleven  days,  according  to  Waller,  and  in 
my  own  case  they  usually  lasted  from  ten  to  fourteen  days." 

I  have  several  times,  with  the  view  of  studying  the  resulting  phe- 
nomena, frozen  my  left  ulnar  nerve  by  throwing  upon  the  skin  over  it, 
where  most  superficial,  the  vapor  of  ether.  I  have  not,  however,  been 
able  to  add  much  to  the  account  of  the  symptoms  given  by  Mitchell 
By  means  of  Lombard's  instrument  I  have  observed  the  rise  of  temp«  ra- 
ture  spoken  of  by  Mitchell,  but  have,  I  think,  ascertained  that  in  the 
very  beginning  of  the  operation  the  temperature  is  slightly  <! 
and  that  it  is  not  till  the  freezing  process  is  well  advanced  that  the 
temperature  rises. 

Congestion  is  probably  the  condition  present  in  many  cases  of  pain 
in  nerves,  which  usually  pass  for  neuralgia.  This  is,  1  think,  especially 
apt  to  be  the  case  when  with  the  pain  there  is  either  clonic  spasm  or 
paralysis  of  certain  muscles  supplied  by  the  affected  nerve,  or  both 

mena.     It  is  also  doubtless  the  primary  condition  of  n 
rit is. 


806  DISEASES   OF  THE   PERIPHERAL   NERVOUS  SYSTEM. 

CHAPTER   II. 

ACUTE   NEURITIS. 

Symptoms. — When  the  affected  nerve  is  superficial  it  may  be  felt  as 
a  hard  cord  under  the  skin,  pressure  upon  which  causes  an  aggravation 
of  the  pain  of  which  it  is  always  the  seat.  The  skin  over  it  is  gener- 
ally red,  showing,  therefore,  the  course  of  the  nerve. 

If  the  nerve  is  a  compound  one,  the  parts  to  which  it  is  distributed 
are  the  seat  of  symptoms  resulting  from  the  disturbance  of  physiologi- 
cal function.  There  is  pain,  and  there  is  either  spasm  or  paralysis,  or 
both.  The  pain  in  the  nerve-trunk,  as  well  as  that  in  the  parts  which 
it  supplies,  is  increased  at  night,  and  there  may  be  sympathetic  pains  in 
other  and  distant  parts  of  the  body.  As  the  morbid  process  advances, 
the  tactile  sensibility  in  the  parts  of  distribution  become  less,  and  after 
a  time  may  be  entirely  abolished,  but  the  perception  of  pain  is  not  lost. 

Reflex  excitability  is  diminished  from  the  first  or  almost  from  the 
first,  and  the  muscles  supplied  by  the  nerve  undergo  atrophy  unless  the 
disease  soon  subsides.  The  temperature  of  the  parts  to  which  the 
nerve  is  distributed  is  increased  3°  or  4°  Fabr.  The  electrical  excita- 
bility of  the  nerve  is  at  first  increased,  but  shortly  the  reactions  of  de- 
generation (page  28)  can  readily  be  obtained. 

If  the  inflamed  nerve  is  only  sensory  in  function,  as,  for  instance, 
the  ophthalmic  branch  of  the  fifth,  the  manifestations  are  mainly  as  re- 
gards sensibility,  although  even  here  motility,  as  shown  by  the  occur- 
rence of  clonic  spasms  in  the  face,  is  reflectively  disturbed. 

In  cases  of  inflammation  of  motor  nerves,  spasm  and  paralysis  are 
the  chief  symptoms,  the  latter  being  the  permanent  condition  should 
the  functions  of  the  nerve  not  be  restored. 

The  skin  covering  the  parts  supplied  by  the  diseased  nerve  is  often 
the  seat  of  an  erythematous  or  bullous  affection. 

In  one  of  Mitchell's  cases  there  was  sudden  oedema  developed  within 
three  days,  and  a  week  later  neural  arthritis. 

It  is  rarely  the  case  that  acute  neuritis  ends  in  complete  resolution. 
Mitchell  never  observed  a  case  of  the  kind.  Jaccoud,  however,  speaks 
of  it  as  terminating  either  by  complete  cure,  that  is  to  say  by  a  cessa- 
tion of  the  pain  and  return  of  the  normal  functions  of  the  nerve,  or  by 
the  supervention  of  permanent  anaesthesia  or  paralysis,  or  both,  accord- 
ing to  the  function  of  the  affected  nerve. 

The  paralysis  not  infrequently  met  with  as  a  consequence  of  long- 
continued  exposure  to  cold  is  probably  the  result  of  neuritis.  Duchenne  ' 
so  regards  it.  Several  cases  of  the  kind  have  come  under  my  notice, 
and  the  majority  have  been  in  the  radial,  the  ulnar,  and  the  posterior 
circumflex  nerves.     The  symptoms  were  similar  to  those  just  detailed, 

1  "  Dc  l'elSctrisation  localise,"  Paris,  1872,  p.  692. 


ACUTE  NEURITS.  -u; 

except  that  there  was  little  or  no  pain.  Indeed,  in  non-traumatic  acute 
neuritis  the  presence  of  these  pains  is  quite  an  exceptional  circumstance, 
whereas,  in  the  secondary  form  of  the  disease  resulting  from  traumatism, 
pain  is  a  prominent  characteristic. 

Causes. — Acute  neuritis  is  not  often  met  with  as  an  idiopathic  affec- 
tion. Generally,  it  is  caused  by  wounds  or  injuries,  or,  as  in  a  case, 
mentioned  by  Mitchell,  by  the  extension  of  cancerous  ulceration. 
It  appear.-,  however,  sometimes  to  be  very  difficult  to  excite  even  by 
extensive  injuries,  or  by  exposure  to  the  action  of  the  atmosphere  or 
other  extraneous  agents.  I  have  repeatedly  Been  the  trunks  of  1 
nerves  exposed  and  subjected  to  irritations  of  various  kinds,  both  in 
man  and  in  the  lower  animals,  without  the  supervention  of  neuritis. 
It  is,  however,  on  the  other  hand,  common  enough  as  a  consequence  of 
wounds,  especially  of  those  of  a  lacerated  character  inflicted  on  nerve- 
trunks.  The  terminal  branches  of  nerves  do  not  appear  to  be  so  readily 
affected.  As  we  have  seen,  it  may  result  from  cold  ;  it  is  also  produced 
by  exudations  from  the  tissues  through  which  the  nerve  passes,  and,  as 
Leudet '  has  shown,  by  the  inhalation  of  carbonic  oxide. 

Diagnosis. — From  neuralgia  it  is  distinguished  by  the  history  of  the 
case,  where  traumatism  is  a  feature,  by  the  tacts  thai  the  temperature 
of  the  parts  supplied  by  the  affected  nerve  is  always  elevated,  which 
is  not  the  case  in  neuralgia,  by  the  persistence  of  the  pain,  and  by  the 
circumstance  that,  except  in  traumatic  acute  neuritis,  the  pain  is  not 
excessive.  The  occurrence  of  paralysis,  spasm,  or  anaesthesia,  or  all  of 
these  symptoms  in  neuritis,  and  their  absence  in  neuralgia,  will  also 
■  to  distinguish  the  one  disease  from  the  other. 

From  cerebral  or  spinal  disease  acute  neuritis  is  readily  diagnosti- 
cated by  the  absence  of  central  symptoms  and  by  the  restricted  limits 
of  the  morbid  phenomena. 

Prognosis. — The  prognosis  in  cases  of  idiopathic  scute  neuritis  is 
not  unfavorable;  I  he  disease  may  be  entirely  dissipated,  leaving  the  fune- 
tinns  of  the  nerve  slightly,  if  at  all,  impaired.  Sometimes,  and  < 
dally  in  traumatic  case-,  the  tendency  is  to  the  continuance  of  the  mor- 
bid process  in  a  chronic  Form  to  the  point  of  producing  profound  Lesions 
of  the  nerve-tissue.  Or,  as  Mitchell  say-,  it  may  be  the  prime  factor 
in  the  proline! ion  of  neuralgia,  causalgia,  joint-disease,  and  local  pal 

Morbid  Anatomy  and  Pathology.— The  l<  aion  generally  invoh 
both  the  neurilemma  and  the  proper  nerve-elements.     The  v< 
are   enlarged,  and  often   extravasations  lake  place.    The  connective 
increased  in  amount,  and  an  exudation  ,<\  serous  or  sero-fibri- 
nous  fluid,  \\  i  1 1 1  a  tendency  to  coagulation,  is  formed.    The  tissues  in 

the  immediate  vieinity  of   the   i iitlanu  >1    nerve  participate    mOJ 

in  the  morbid  action. 

'  ■•  l ;. .  1  ii  t  troubles  di  rlph6rique  iurtoat  del 

-i-rutii-  a  L'uphyxio  p*i  li  rapeur  de  charbon,"  Archi 


808  DISEASES    OF   THE   PERIPHERAL   XERVOUS   SYSTEM. 

If  resolution  results,  these  products  are  absorbed,  and  the  nerve 
regains  its  normal  condition ;  if,  however,  suppuration  ensues,  little 
abscesses  form  within  the  sheath  of  the  nerve,  or  between  its  fibres; 
these  latter  become  completely  disorganized  through  granular  degenera- 
tion, and  eventually  constitute  an  amorphous  mass  of  oil-globules  and 
debris  contained  within  the  neural  sheath. 

The  pathology  of  neuritis,  like  that  of  other  diseases,  is  to  be  stud- 
ied from  the  stand-point  of  the  normal  physiology  of  the  healthy 
nerve — and  there  is  little  to  add  to  the  remarks  already  made  under 
the  head  of  symptoms.  The  fact  should.be  borne  in  mind  that  irrita- 
tions applied  to  a  nerve-centre  or  a  nerve-trunk  are  more  acutely  felt  at 
the  points  of  distribution  of  the  nerve  than  at  the  seat  of  the  irritation. 
Of  course,  in  accordance  with  a  well-known  law,  irritations  made  to  a 
motor  or  compound  nerve-trunk  cause  spasms  in  the  muscles  to  which 
the  nerve  is  distributed.  The  first  stages  of  inflammation  constitute  an 
irritative  process.  Hence  the  clonic  contractions  which  are  present  in 
the  early  periods  of  the  affection.  But,  as  the  morbid  action  proceeds, 
the  irritability  and  conductivity  of  the  nerve  become  abolished,  and 
therefore  the  clonic  spasms  cease,  and  voluntary  power  in  the  muscles 
supplied  by  the  diseased  nerve  is  lost. 

Treatment. — Mitchell,  in  the  only  case  of  acute  neuritis  of  which  he 
had  the  control  from  the  beginning,  enveloped  the  arm  from  above 
the  wound  to  the  finger-ends  in  bladders  of  ice  and  water  ;  the  limb 
was  elevated  above  the  body,  and  one  twenty-fifth  of  a  grain  of  sul- 
phate of  atropia,  combined  with  one-quarter  grain  of  sulphate  of  mor- 
phia, was  given  in  solution  every  four  hours  or  oftener  if  needed. 

Jaccoud  recommends  leeches,  and  even  cups  over  the  course  of  the 
nerve.  The  latter  must  certainly  cause  suffering,  and  Mitchell  states 
that  even  leeching,  though  sometimes  beneficial,  causes  great  pain,  and 
that  the  leech-bites  are  prone  to  inflame. 

In  the  cases  of  acute  neuritis  resulting  from  cold  which  have  been 
under  my  charge  I  have  obtained  decided  benefit  from  the  use  of  the 
primary  galvanic  current  of  great  intensity,  the  application  being  made 
through  wet  sponges  drawn  over  the  skin  covering  the  affected  nerve. 
Two  applications,  each  lasting  half  an  hour,  should  be  made.  Each  one 
is  followed  by  a  diminution  of  the  pain  and  numbness,  and  a  lessening 
of  the  spasms  of  the  muscles. 

At  the  same  time  I  have  employed  deep  injections  of  sulphate  of 
morphia  combined  with  sufficient  sulphate  of  atropia  to  counteract  its 
unpleasant  effects — one-fourth  grain  of  the  morphia  with  the  one- 
sixtieth  of  atropia  being  about  the  doses  to  begin  with.  Two  injections 
should  be  made  daily.  I  endeavor  to  touch  the  nerve  with  the  point  of 
the  syringe,  or,  failing  that,  to  come  as  near  to  it  as  possible. 

Hot  applications  to  the  inflamed  nerves  give  a  great  deal  of  com- 
fort to  the  patient  and  assist  in  reducing  the  congestion. 


SCIATICA.  g09 

The  good  effects  of  this  treatment  are  generally  very  evident,  and 
a  cure  is  ordinarily  accomplished  in  at  most  a  week. 

In  two  cases  of  inflammation  of  the  radial  nerve,  apparently  resum- 
ing from  long-continued  exposure  to  cold  and  dampness,  which  have 
recently  been  under  my  care,  1  have  applied  the  actual  cautery  along 
the  whole  course  of  the  inflamed  portion  of  the  nerves.  The  effect 
was  an  arrest  of  the  pain,  the  numbness,  and  the  muscular  spasms,  and 
the  continual  relief  of  all  the  symptoms  by  the  subsequent  injections  of 
morphia  and  atropia  for  two  or  three  days.  In  both  of  these  cases  the 
tract  of  the  inflamed  nerve  was  marked  by  cutaneous  redness. 

After  the  disappearance  of  the  acute  symptoms,  if  any  ansesthesia 
or  paralysis  remains,  it  is  to  be  treated  with  the  induced  or  primary 
current,  as  may  seem  most  advantageous  by  actual  experiment.  I  am 
inclined  to  think  that  both  currents  should  be  used,  the  primary  unin- 
terrupted for  the  relief  of  the  anaesthesia  and  for  improving  the  con- 
ductivity of  the  nerve,  and  the  induced  to  the  muscles  for  the  restora- 
tion of  their  irritability.  At  the  same  time,  passive  mot  inns,  frictions 
with  hair-gloves,  and  applications  of  hot  water,  arc  beneficial. 

It  must  not  be  forgotten  that  in  the  early  stages,  and  all  through 
the  active  period  of  the  disease,  alsolute  rest  must  be  as  nearly  as  pos- 
sible secured.  Every  muscular  contraction  of  a  limb  containing  an 
inflamed  nerve  causes  intense  suffering,  and  can  scarcely  fail  to  aggra- 
vate the  disease. 

Constitutional  treatment  beyond  such  as  may  be  necessary  to  main- 
tain or  increase  the  tone  of  the  system  is  not  ordinarily  required. 


CHAPTER   III. 
a  <  /  i  no  A. 

Tins  form  of  neuritis  is  characterized  by  the  occurrence  of  pain  in 
the  course  of  the  sciatic  nerve  and  its  branches,  mainly  in  those  dis- 
tributed to  the  skin.     It  may  he  restricted  t<>  the  gluteal  region  and 

Upper  part  of  the  thigh,  <>r  may  extend   to  the   sole  of   the  foot  or  I 
The  principal  painful   points  are  those  which   correspond  to  the  sacral 

foramina,  where  the  large  and  small  sciatic  nerves  emerge  from  the 
pep  i  ies  corresponding  to  the  emergence  of  cutaneous  branches 

through  the  fascia,  a  fibular  point  at  the  head  of  the  lihula,  an  external 
malleolar,  and  an  internal  malleolar. 

Sciatica  g<  nerally  begins  a-  a  dull,  heavy  ache,  which  gradually  be- 
comes  more  and    more   intense,  and    which,  like  all  I  he  ot  her  forms  of 

neuralgia,  is  aggrai  ated  by  muscular  exertion.     It  is  subject  toexsoer* 

bations  of  riolenoe,  during  which  the  least  agitation  of  the  body  still 


810  DISEASES   OF   TOE   PERIPHERAL   NERVOUS   SYSTEM. 

further  increases  the  intensity  of  the  suffering.  Sometimes  the  pain 
darts  through  the  nerves  like  electric  shocks,  while  at  others  it  retains 
its  original  situation.  It  is  often  accompanied  by  muscular  contrac- 
tions. Anaesthesia  is  generally  present  in  the  parts  which  are  or  have 
been  the  seats  of  the  pain,  and  can  readily  be  detected  with  the  sesthe- 
siometer. 

A  patient  who  has  once  had  an  attack  of  sciatica  becomes  thereby 
more  liable  to  others.  The  nerve,  after  the  full  force  of  the  disease  is 
spent,  remains  in  a  more  or  less  irritable  state,  during  which  it  is  par- 
ticularly liable  to  a  fresh  outbreak,  and,  even  when  this  does  not  occur, 
it  is  quite  common  for  the  patient  to  be  reminded,  on  any  little  extra 
excitation  or  exposure  to  cold,  that  he  has  a  master  ready  on  the  least 
sign  of  rebellion  to  put  the  screws  to  his  refractory  subject.  These 
remarks  are  applicable  to  all  forms  of  neuritis,  but  they  appear  to  me 
to  be  specially  so  to  sciatica.  Sometimes,  even  when  the  individual 
remains  perfectly  still  and  has  committed  no  indiscretion,  there  are 
sharp,  shooting  pains,  which  follow  the  course  of  the  sciatic  nerve  and 
its  branches. 

Causes. — The  etiology  of  sciatica  is  not  materially  different  from 
that  of  ordinary  neuritis,  except  so  far  as  it  is  modified  by  local  circum- 
stances. Among  these  Tatter  are  enlargement  of  the  prostate  gland, 
by  which  pressure  is  exerted  on  the  nerve,  various  tumors  of  the  ab- 
dominal organs,  the  pressure  of  the  foetal  head  in  childbirth,  accumu- 
lations of  faeces  in  the  large  intestine,  etc.  It  is  also  occasionally  in- 
duced by  the  pressure  on  the  nerve  which  results  from  sitting  long 
on  a  hard  chair.  Several  cases  of  this  kind  have  come  under  my  obser- 
vation. 

I  have  also  noticed  the  fact  that  sciatica  is  often  developed  with 
great  suddenness  on  the  patient  making  some  unusual  exertion  of  the 
limb.  In  such  cases  the  effort  is  probably  only  the  spark  which  lights 
up  the  flame. 

In  regard  to  the  influence  of  gout,  rheumatism,  and  syphilis  as  fac- 
tors in  the  production  of  sciatica,  I  think  there  is  considerable  doubt. 
It  is  possible,  in  a  very  small  percentage  of  cases,  that  these  diseases 
may  predispose  the  patient  to  sciatica,  or  may  perhaps  induce  it  pri- 
marily, but  clinical  evidence,  at  least  in  my  experience,  does  not  give 
much  support  to  the  rheumatic,  gouty,  or  syphilitic  origin  of  sciatica. 
Gowers  '  believes  that  both  rheumatism  and  gout  are  "potent  factors 
in  the  production  of  sciatica,"  but  holds  that  "  cases  in  which  the 
syphilitic  nature  of  the  disease  is  certain  are  extremely  rare."  Anstie,2 
on  the  other  hand,  remarks  :  "But  so  far  from  agreeing  with  those 
who  think  this  (rheumatism)  is  a  frequent  case,  my  experience  teaches 
me  that  it  is  quite  exceptional ;  nor  do  I  believe  that  the  common 
opinion  could  ever  have  arisen  had  it  not  been  for  the  rage  that  exists 

1  "  Diseases  of  the  Nervous  System."  2  "  Neuralgia,"  etc. 


SCIATICA.  811 

for  connecting  every  disease  with  a  special  diathesis  which  the  pr< 
sion  flatters  itself  that  it  understands."     He  is  even  more  emphatic  in 
his  denunciation  of  gout  as  a  cause  of  sciatica,  and  concludes  with  the 
remark  that,  in  his  experience,  syphilis  is  but  rarely  concerned  in  pro- 
ducing it. 

My  own  clinical  experience  leads  me  to  adopt  Anstie's  v 
Rheumatism,  gout,  and  syphilis  are  very  common  diseases  in  this 
country,  and  yet  it  is  extremely  rare  to  find  an  individual  suffering 
from  any  one  of  them  who  also  suffers  from  sciatica.  My  experience 
in  this  connection  has  shown  that  the  vast  majority  of  cases  of  sciat- 
ica have  never  suffered  from  rheumatism,  gout,  or  syphilis,  and  that 
of  the  hundreds  of  cases  of  rheumatism,  gout,  and  syphilis,  a  very  in- 
finitesimal proportion  have  even  had  sciatica.  Another  factor  against 
the  theory  of  rheumatism  and  gout  causing  sciatica  is  that  anti-rheu- 
matic and  anti-goutic  remedies,  while  they  relieve  the  rheumatism  and 
gout,  fail  utterly  to  improve  the  sciatica  in  the  li  ast.  Again,  no  post- 
mortem evidences  of  gout  or  rheumatism  can  be  found  in  the  sciatic 
Qervefl  after  death. 

It  is  very  probable  that  both  rheumatism  and  gout  lower  the  tone 
of  the  Bystem  to  such  an  extent  as  to  render  the  patienl  more  liable  to 
an  atta<  k  of  sciatica  than  he  otherwise  would  have  been  ;  but  there  Lfl 
little  or  no  evidence  to  show  that  either  of  these  diseases  directly  pro- 
duces sciatica,  or  neuritis  in  any  other  part  of  the  body,  by  direct 
action. 

Syphilis  has  been  known,  in  rare  instances,  to  cause  sciatica,  either 
by  tin-  pressure  from  gummata  on  the  nerve-trunk  or  by  causing  in- 
flammation in  the  nerve-sheath  by  the  direct  action  of  the  syphilitic 
poison  in  the  system.  In  regard  to  the  latter,  I  am  as  skeptical  .  -  I 
am  that  the  poisons  of  rheumatism  and  !_rout  directly  produce  inflam- 
mation in  the  -heath  or  substance  of  the  sciatic  nerve. 

Reports  of  cases  of  sciatica  directly  traceable  to  syphilis  are  un- 
common.    Only  two  such  cases  have  come  under  my  observation. 

romata,  traumatism  (which  inoludes  blows,  falls,  wounds,  and 
muscular  efforts),  and  intra-pelvic  ami  extra  pelvic  tumors,  all  produce 

tica   by  the    irritation  of   pressure,    which,    if   it    i-   continued    long 

enough,  induces  neuritis.     I  of  bones  and  joints  cause  sciatioa 

by  the  extension  of  inflammation  to  the  sciatic  nerve. 

The  Diagnosis  is  not  a  matter  of  any  difficulty,  though  I   have 

many  tie  -   mi-taken   for  di  '    the  spinal   oord,  and 

The  Prognosis  depends  greatly  on  the  ability  to  remove  the 
can  le. 

Morbid  Anatomy  uology.     In  mild  I  probably  in 

the  initial  stage  of  ;ill  cases,  the  inflammation  is  limited  to  the  -heath 
of  thi  .  the  irritation  of  the  delicate  nervi  nervorum  accounting 


812  DISEASES  OF  TIIE   PERIPHERAL  NERVOUS  SYSTEM. 

readily  for  the  localized  pain  along  the  course  of  the  nerve.  In  severe 
cases  there  is  not  only  inflammation  of  the  nerve-sheath,  but  there  is 
also  inflammation  of  the  interstitial  tissue,  which,  by  its  increase  in 
volume,  and  consequent  pressure  iipon  the  nerve-fibres,  may  induce 
atrophy  and  degeneration  of  the  nerve  and  consequent  atrophy  and 
paralysis  of  many  of  the  leg  muscles.  There  is  also,  in  the  majority 
of  cases,  an  exudation  of  leucocytes  between  the  nerve  and  its  sheath, 
which,  by  distending  the  nerve-sheath,  probably  accounts  for  some  of 
the  pain. 

Treatment. — It  must  therefore  be  understood,  from  the  preceding 
remarks,  that  sciatica,  no  matter  what  its  source  of  origin  may  be,  is 
to  be  regarded  as  a  neuritis,  and  is  to  be  treated  as  such.  Of  course, 
if  the  neuritis  has  been  induced  by  injury,  by  pressure,  or  by  the  ex- 
tension of  inflammation,  it  is  absolutely  necessary  that  these  condi- 
tions should  be  removed  ;  but  by  simply  removing  the  original  cause 
of  the  irritation,  the  pain  is  not  always  arrested.  In  the  mean  time 
the  constant  irritation  of  the  sciatic  nerve  has  resulted  in  a  neuritis, 
which  may  remain  long  after  the  original  source  of  irritation  has  been 
removed. 

Considering,  then,  that  we  have  to  deal  with  an  ordinary  case  of 
sciatica  due  to  exposure  to  cold,  or  that  we  have  successfully  removed 
the  original  cause  of  the  sciatica,  and  the  pain  still  continues,  what  is 
the  most  rational  plan  of  treatment  to  be  adopted  ?  Pathologically 
we  have  to  deal  with  inflammation  of  the  sheath  of  the  nerve  and  per- 
haps of  the  nerve  itself,,  and  with  a  sero-fibrinous  exudation,  which  is 
usually  between  the  sheath  and  the  nerve,  but  is  sometimes  in  the 
substance  of  the  nerve  itself.  Clinically  we  are  confronted  by  pain, 
which  may  be  slight  or  agonizing,  continuous  or  only  present  on 
motion,  and,  in  old  cases,  by  a  certain  amount  of  atrophy  of  some  of 
the  muscles. 

For  the  relief  of  pain  the  remedies  used  should  vary  with  the  ex- 
tent of  the  suffering.  In  the  most  severe  cases,  where  the  suffering  is 
intense,  it  is  absolutely  necessary  to  use  morphine.  When  such  is  the 
case,  it  should  be  given  hypodermically  in  doses  amply  sufficient  to 
relieve  all  pain,  and  should  be  injected  hypodermically,  and  not  given 
by  the  mouth  ;  the  fluid  should  be  injected  as  near  the  nerve  as  possi- 
ble, as  there  is  some  reason  to  believe  that  morphine  has  a  tendency  to 
reduce  the  inflammation  in  a  nerve  when  brought  in  contact  with  it. 
In  milder  cases,  phenacetine,  in  a  single  dose  of  fifteen  grains,  which 
can  be  repeated  in  an  hour  if  necessary,  will  be  found  to  fulfill  all 
requirements.  Antipyrine  and  antifebrine  can  be  used  in  place  of 
phenacetine  if  desired.  I  have  never  seen  any  benefit  derived  from 
the  internal  administration  of  aconitine,  atropine,  gelsemium,  or  tur- 
pentine, remedies  which  are  claimed  to  be  very  useful  in  relieving  the 
pain  of  sciatica. 


SCIATICA.  813 

To  relieve  the  neuritis  itself,  I  depend  almost  entirely  upon  rest, 
the  application  of  cold,  and  the  use  of  electricity. 

In  regard  to  the  value  of  rust  in  the  treatment  of  sciatica,  there 
can  be  no  doubt.  Every  time  the  leg  is  moved,  the  functions  of  the 
M-iatic  nerve  are  called  into  play.  It  is  well  known  that  the  use  of 
nerves  and  muscles  induces  a  temporary  congestion  of  the  parts  at 
which  would  only  have  a  tendency  to  aggravate  a  condition  of  already 
existing  inflammation.  Now,  by  rest  I  do  not  mean  simply  forbidding 
a  patient  to  walk  about,  or  even  confining  him  to  his  bed,  but  I  mean 
absolute  rest  to  the  limb,  which  can  only  be  obtained  by  putting  the 
patient  in  bed  and  applying  a  suit  aide  splint  to  the  leg.  The  splint  I 
always  use  is  the  old-fashioned  long  splint,  reaching  from  the  axilla 
to  the  sole  of  the  foot.  It  should  be  attached  to  the  body  by  means 
•  ■fa  bandage,  and  in  the  same  manner  fastened  to  the  leg  from  the 
ankle  upward  to  a  point  just  above  the  patella.  This  leaves  the  thigh 
and  the  sole  of  the  foot  uncovered,  a  proceeding  which  is  necessary 
for  the  proper  application  of  the  cold  and  electricity.  The  idea  of 
using  a  splint  in  cases  of  sciatica  is  not  original  with  me,  though  per- 
haps the  method  of  using  it  is.  The  splint  was  first  advocated  by  Dr. 
S.  Weir  .Mitchell  several  years  ago,  and  is,  I  believe,  still  frequently 
used  by  him.  It  <_dves  the  leg  absolute  rest,  and  should  be  used  in  all 
severe  cases.  In  very  mild  cases  it  is  not  necessary.  About  every 
fourth  day  it  should  be  removed,  and  passive  movements  of  the  joints 
and  slight  manipulations  of  the  muscles  should  be  carefully  made, 
after  which  the  splint  should  be  readjusted. 

Cold  is  a  most  serviceable  therapeutic  agent.  I  am  aware  that  re- 
frigerating the  skin  over  the  course  of  the  sciatic  nerve  with  sprays  of 
chloride  of  methyl,  ether,  and  other  agents  which  produce  Intense  cold 
has   lie.  n    advocated    and    is  frequently    used.      I   have  employed  these 

remedies,  and,  after  a  careful  trial  of  them,  it  does  not  seem  to  me 
that  they  are  as  efficacious  as  a  more  moderate  degree  of  temperature 

( tinuously  applied.     It   is  my  custom  now  to  apply  cold  by  m< 

of  ice-bags  packed  against  the  posterior  surface  of  the  thigh.     This 

can  readily  be  done  with  the  splint  on  if  it  is  adjusted  in  the  manner 
just  described.  My  reason  for  preferring  this  form  of  cold  is  that,  i1 
being  continuous,  it  soon  reaches  the  nerve,  and  materially  aids  in  sub- 
duing the  inflammation;  as  the  oold  is  nol  intense,  the  skin  i    never 

frozen.  My  objection  to  the  sprays  of  chloride  of  meth;  I,  ether,  and 
Other    freezing   sprays    is    that    the   cold  is  BO  great    that    the   skin    soon 

ind  the  application  has  to  lie  discontinued  before  the  bene* 
ticial  results  of  the  oold  can  be  experienced  by  the  inflamed  nerve. 
This  is  particularly  true  of  the  chloride  of  methyl,  which  freezes  the 

skin  as  soon  as  it  come-,  in  ty  ntaH  with  it.  It  seems  to  uie  that  where 
the    chloride    of    methyl    ads    beneficially    at    all,    it    must    do    s,,   :[s   a 

counter-irritant,  and  not  as  a  refrigerant.     In  my  opinion  the  ether 


814  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

spray  is  far  superior  to  it,  as  it  is  of  a  lesser  degree  of  cold,  and 
can  therefore  be  applied  for  a  much  longer  time  ;  but  neither  of 
these  agents  can  compare  to  the  almost  continuous  application  of  the 
ice-bags. 

Electricity,  when  properly  applied,  is  one  of  the  most  useful  and 
important  remedies  we  possess  for  the  treatment  of  sciatica,  but  when 
improperly  used  only  serves  to  aggravate  the  disease  and  retard  the 
recovery  of  the  patient. 

The  faradaic  current  should  not  be  used  at  all  in  acute  sciatica. 
It  is  an  irritating  current,  both  to  nerves  and  to  muscles,  and  is  there- 
fore contra-indicated.  After  the  neuritis  has  disappeared  and  the  mus- 
cles have  become  flabby  from  disease,  or  in  old  cases,  where  the  nerve 
has  been  damaged  and  atrophy  of  muscles  has  resulted,  faradaic  appli- 
cations may  be  beneficial,  but  in  acute  sciatica  it  should  never  be  used. 

The  galvanic  current  may  be  applied  in  two  ways  :  as  a  continu- 
ous current,  and  as  an  interrupted  current.  There  is  the  same  objec- 
tion to  the  interrupted  galvanic  current  that  there  is  to  the  faradaic — 
that  is,  that  it  is  irritative.  Both  of  these  interrupted  currents  are 
antagonistic  to  the  principle  of  absolute  rest,  which  I  believe  to  be  so 
important  a  factor  in  the  treatment  of  severe  sciatica.  The  continu- 
ous galvanic  current,  on  the  other  hand,  is  of  great  service.  It  allays 
pain,  probably  in  part  by  the  anaesthetic  properties  of  its  positive  pole, 
probably  in  part  by  reducing  the  inflammation  in  the  nerve.  In  what 
manner  it  relieves  the  neuritis  is  not  known.  It  is  claimed  that  it 
promotes  the  absorption  of  the  serous  exudation  between  the  nerve 
and  its  sheath.  However  this  may  be,  it  unquestionably  does  relieve 
the  patient,  and  in  many  instances  no  other  remedy  is  necessary  except 
rest.  Its  manner  of  application  is  as  follows  :  The  negative  electrode 
should  be  about  nine  by  four  inches  in  size,  and  should  be  strapped  to 
the  sole  of  the  foot  by  elastic  bands.  The  positive  electrode  should 
be  about  five  or  six  inches  square,  and  should  be  applied  over  the  glu- 
teal region,  over  the  point  where  the  sciatic  nerve  emerges  from  the 
pelvis.  If  there  are  any  very  tender  spots  along  the  course  of  the 
nerve,  this  electrode  can  be  changed  occasionally  so  as  to  cover  them. 
The  strength  of  the  current  should  not  be  such  as  to  cause  much  pain, 
but  should  fall  just  short  of  doing  so.  No  rule  as  to  the  current- 
strength  to  be  employed  can  be  laid  down,  as  the  point  of  toleration  is 
different  in  different  individuals.  The  continuous  current  should  be 
applied  twice  daily,  if  possible,  certainly  once  a  day,  for  about  five  min- 
utes at  each  seance.  Most  of  the  text-books  recommend  that  at  the  end 
of  each  application  of  the  continuous  current  a  number  of  interruptions 
should  be  made  in  order  to  stimulate  the  muscles.  Nothing  of  the 
sort  should  be  done.  It  is  opposed  to  the  scientific  treatment  of  the 
disease.  It  irritates  the  nerve,  and  counteracts,  in  part,  if  not  alto- 
gether, the  benefit  derived  from  the  continuous  current. 


MULTIPLE   NEURITIS.  gxfi 

As  for  the  internal  administration  of  drags,  there  is  very  litl 
he  said.     In  those  cases  which  arc  unquestionably  syphilitic,  of  00 
anti-syphilitic  treatment  is  indicated      In  all  other  ./ink   the 

iodide  of  potassium  can  be  given,  in  gradually  increasing  doses,  with 
great  advantage,  as  it  acts  energetically  in  promoting  the  absorption 
of  the  serous  exudation,  and  prevent-,  in  a  i_Mv.it  measure,  the  forma- 
tion of  new  connective  tissue. 

Regarding  sciatica  from  its  pathological  standpoint,  it  sei  mi  to  me 
that  the  measures  just  alluded  to— that  is.  absolute  rest,  the  applica- 
tion of  modi  rate  hut  continuous  cold,  ami  the  proper  administration  of 
the  continuous  galvanic  current— constitute,  with  proper  anodynes,  to 

temporarily   relieve    pain,  the   rational    and    scientific  treatment  of  the 

disease.  In  cases  of  moderate  severity,  n  st,  together  with  galvanism, 
will  be  the  only  remedies  required. 

In  regard  to  other  forms  of  treatment  a  word  musl  '»e  said. 

The  use  of  colchicum,  salicylic  acid,  salol,  oil  of  wint.  rgrei  a,  ami 
other  anti-gout ic  aid  anti-rheumatic  remedies,  have  not  been  followed 
by  beneficial  results  in  my  cases,  even  where  goul  or  rheumatism  has 

complicated  the  case.  Though  the  goul  and  rheumatism  may  yield  to 
these  drugs,  the  sciatica  does  i 

Blisters  or  the  actual  cautery  are  serviceable,  hut  do  not  compare 
to  the  action  of  continuous  cold.     Winn  tl  evere  one, 

blisters  or  the  cautery  may  be  substituted  for  the  cold. 

Hypodermatic  injections  of  various  sul  are  frequently  rec- 

ommended as  curing  cases  of  sciatica.  Among  these  may  he  men* 
tioned  ether,  nitrate  of  silver,  and  osmio  acid.  Their  action  is  so  on- 
certain,  and  their  tendency  to  create  deep-seated  abscesses  is  so  well 
known,  that  I  do  not  advocate  their  use. 

In  which   resisl   all  the  useful  forms  of  •■ 

Stretching  the  BCiatio  nerve  may  he  followed  by  complete  relief. 


CHAPTER    IV. 

/  /'/  J. 


[n  multiple  n  I  nerves  arc  affected  simultam 

if  the  di  ii nerve,  it   is  rapidly  communii  ab  d  t" 

others.      In  the  majority  of  eases  the  d  j  mm.  t  ri.all  \ 

either  in  both  legs,  in  both  arms,  or  in  all  four  extreiniti.  -. 

Symptoms.— Sometimes  t!  maj  be  ush<  red  in  by  a  .hill  or 

l.\    chilly  sensations  followed  soon  by  a  rapid  rise  in  temperature, 

which,  however,  rare!  hr.,  or  there  m:i\    be  DO  febrile 


816  DISEASES   OF   THE   PERIPHERAL  NERVOUS   SYSTEM. 

disturbances  whatever.  The  first  local  symptoms  which  attract  the 
patient's  attention  are  sensory  in  character.  Numbness  and  tingling 
in  the  fingers  and  toes  is  soon  followed  by  pain,  slight  at  first,  but 
quickly  increasing  in  intensity  until,  in  some  instances,  it  is  almost 
unendurable.  Occasionally  the  pain  is  paroxysmal,  subsiding  after 
each  exacerbation,  but  never  completely  disappearing.  The  muscles 
become  painful  and  are  tender  to  the  touch,  and  pressure  upon  the 
nerve-trunks  always  gives  rise  to  a  great  deal  of  pain. 

Paresis  makes  its  appearance  early  in  the  disease,  but  is  confined, 
however,  to  those  muscles  which  are  supplied  by  the  inflamed  nerves. 
In  severe  cases  there  may  be  complete  paralysis.  Atrophy  of  the 
paralyzed  muscles  is  often  a  prominent  symptom,  and  in  severe  and 
chronic  cases  progresses  steadily  until  almost  all  of  the  muscular  tissue 
has  disappeared. 

The  tactile  sense,  the  temperature  sense,  and  the  muscular  sense 
are  always  diminished  and  are  sometimes  abolished.  The  patellar- 
tendon  reflex  is  invariably  lost  and  the  electrical  "  degenerative  reac- 
tions "  (see  page  28)  can  usually  be  obtained  except  in  very  slight  ex- 
amples of  the  disease.  There  may  be  other  trophic  changes,  such  as 
degeneration  and  proliferation  of  the  skin,  brittleness  of  the  nails,  and 
loss  of  hairs. 

Causes. — Alcoholism  probably  gives  rise  to  more  cases  of  multiple 
neuritis  than  all  the  other  causes  combined.  It  also  follows  exposure 
to  cold,  from  some  of  the  acute  febrile  diseases  and  from  toxic  condi- 
tions of  the  blood. 

Diagnosis. — Multiple  neuritis  is  more  liable  to  be  mistaken  for 
locomotor  ataxia  than  for  any  other  affection.  In  severe  cases  of 
multiple  neuritis  the  danger  of  error  is  slight.  The  inflamed  nerves 
are  both  motor  and  sensory  in  character  ;  hence,  in  addition  to  the 
sensory  symptoms,  which  may  be  identical  with  those  of  ataxia,  there 
is  paralysis,  atrophy  of  muscles,  and  the  electrical  reactions  of  degen- 
eration, none  of  which  are  present  in  ataxia  except  in  a  very  advanced 
state.  In  mild  cases  of  neuritis  the  diagnosis  may  be  more  difficult. 
In  such  cases  there  may  be  neither  paralysis,  atrophy,  nor  degen- 
erative reactions.  As  a  general  thing,  the  history  of  alcoholism,  the 
sudden  advent  of  the  symptoms,  the  absence  of  the  sharp  shooting 
pains  which  usually  are  present  in  cases  of  ataxia  for  weeks,  or  even 
months,  before  other  symptoms  appear,  will  materially  assist  in  the 
diagnosis. 

From  anterior  poliomyelitis,  multiple  neuritis  may  readily  be  dis- 
tinguished by  the  presence  of  sensory  symptoms. 

There  are  no  other  affections  with  which  this  disease  is  liable  to  be 
confounded. 

Prognosis. — There  is  seldom  a  fatal  termination  to  multiple  neu- 
ritis unless  the  nerves  supplying  the  respiratory  muscles  are  affected. 


CHRONIC   NEURITIS.  817 

If  the  neuritis  is  of  alcoholic  origin,  the  prognosis  must  necessarily  be 
influenced  by  the  patient  continuing  his  pernicious  habit.     In  ordinary 
cases  recovery  takes  place  in  from  one  to  three  11101  r 
however,  which  are  accompanied  by  a  great  deal  of  atrophy,  may  last 
for  a  year  or  more. 

Morbid  Anatomy  and  Pathology.— The  pathological  changes  which 
characterize  multiple  neuritis  are  similar  to  those  which  occur  in  acute 
neuritis  ami  in  sciatica,  and  do  not  need  to  be  farther  amplified. 

Treatment. — Absolute  rest  is  of  the  greatest  importance.  This  I 
have  insisted  on  in  my  remarks  on  the  treatment  of  sciatica,  and  wbal 
I  said  then  applies  with  equal  force  to  multiple  neuritis.  If  alcohol  is 
the  cause  of  the  disease,  it  should  he  discontinued  at  once  if  it  is  possi- 
ble to  do  so.  Hot  applications  over  the  inflamed  nerves  are  of  great 
service.  They  not  only  reduce  the  inflammation,  but  also  assist  in  re- 
lieving pain.  Electricity  should  be  employed  with  caution.  The 
faradaic  current  is  irritative  and  should  not  be  used  at  all.  The  gal- 
vanic current  may  be  advantageously  applied  in  the  same  manner  that 
I  have  previously  recommended  in  my  remarks  on  sciatica. 

For  the  relief  of  pain,  phenacetine  in  doses  of  fifteen  grains  may 
be  given  at  intervals  through  the  day.  If  the  suffering  is  meat,  phen- 
acetin  will  not  be  effective,  and  morphine  must  he  resorted  t<>.  It 
should,  however,  be  given  with  discrimination  and  should  be  displaced 
by  phenacetine  as  soon  as  possible. 


CHAPTER    V. 

cnnoxic  neuritis  —beural  sclerosis.—  vbubai  atropet. 

Chronic  neuritis  may  result  from  an  attack  of  acute  neuritis;  from 
central  disease — either  of  the  brain  or  spinal  oord,  <>r  it  may  have  an 
idiopathic  origin. 

Symptoms. — The  Bymptoms  vary  in  aooordanee  with  the  physiolo* 
ricaJ  character  of  the  affected  nerve.  If  a  compound  nerve  is  the  seal 
1  the  lesion,  the  phenomena  are  in  the  main  anaesthesia,  paralysis,  and 
muscular  atrophy.  It'  a  sensory  nerve  is  the  one  involved,  anassti 
and  perhaps  nain,  is  the  most  prominent  symptom.  It'  a  nerve 
special  sense  is  affected,  there  is  disturbance  of  the  function  of  the 
nerve  as  regards  the  related  sense,  and  this  may  be  either  of  the  char- 
acter of  hyperesthesia,  ansssthesia,  or  both.  It"  the  diseased  nerve  is 
purely  motor  in  function,  then  the  results  are  motor  paralysis  and  mus- 
cular atrophy. 

We  have  already  had  to  oonsider  to  some  extent  the  soli 
ttrophy  of   ipinal   nerves  in  connection  with  certain  .1 


818  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

primary  seat  is  in  the  spinal. cord.  But  such  nerves  may  be  the  seat 
of  the  lesion  in  question  and  may  give  rise  to  symptoms  similar  in  some 
respects  to  those  due  to  disease  of  that  part  of  the  cord  with  which 
they  are  in  anatomical  and  physiological  relation. 

Disturbances  of  sensibility,  usually  of  the  nature  of  anaesthesia 
rather  than  hyperesthesia  and  paralysis  of  motion  strictly  limited  to 
the  muscles  to  which  the  affected  nerve  is  distributed,  are  the  first 
symptoms.  These  become  more  distinctly  marked  as  the  lesion  ad- 
vances in  its  course,  and  eventually  reach  a  full  state  of  development. 
The  electric  contractility  of  the  muscles  begins  to  diminish  early  in  the 
course  of  the  disease,  and  reflex  excitability  is  also  lessened. 

Secondary  neuritis,  when  resulting  from  spinal  lesion,  may  affect 
either  the  anterior  or  posterior  root  singly  of  one  or  more  nerves.  In 
such  cases  the  eccentric  disturbances  are  connected  with  motion  or  sen- 
sibility, as  the  case  may  be. 

Chronic  neuritis  affecting  a  sensory  nerve  is  not  in  general  charac- 
terized by  very  acute  pain,  and  this  is  accompanied  by  anaesthesia  of 
the  parts  to  which  the  nerve  is  distributed.  As  the  disease  advances 
the  pain  becomes  less,  and  the  anaesthesia  correspondingly  increases. 
The  reflex  excitabilit}'-  of  the  muscles  to  which  the  nerve  is  distributed 
is  diminished  for  the  reason  that  sensory  impressions  are  not  transmit- 
ted in  full  force  along  the  trunk  of  the  affected  nerve,  and  hence  are  not 
promptly,  if  at  all,  converted  into  motor  impulses.  Neuritis  as  affect- 
ing the  nerves  of  special  sense  does  not  come  within  the  scope  of  this 
treatise. 

When  a  purely  motor  nerve,  as  the  facial,  is  the  seat  of  chronic 
neuritis,  the  phenomena  observed  relate  exclusively  to  motion.  In  the 
early  stage  there  is  probably  clonic  spasm  in  the  muscles  supplied  by 
the  nerve,  but  ere  long  paralysis  takes  its  place — atrophy  and  rigidity 
of  the  muscles  soon  follow.  Electric  contractility  and  reflex  excita- 
bility are  early  impaired,  the  latter  on  account  of  the  paralysis  of  the 
muscles,  and  not  from  any  retardation  of  the  passage  of  sensory  im- 
pressions— which  of  course  do  not  travel  through  a  motor  nerve — to  the 
central  organ. 

Chronic  neuritis  often  exhibits  a  tendency  to  ascend  and  to  involve 
more  central  trunks  in  the  inflammatory  process.  Mitchell  speaks  of 
this  as  a  constant  result. 

Causes. — The  most  common  causes  of  chronic  neuritis  are  the 
acute  form  of  the  disease  and  lesions  of  those  parts  of  the  central 
nervous  system  from  which  the  affected  nerves  are  derived.  It  also 
results  when  from  any  cause  whatever  the  peripheral  organs  to  which 
the  nerves  are  distributed  are  prevented  performing  their  normal  func- 
tions. 

Chronic  neuritis  may  originate  primarily  from  wounds  and  injuries 
without  necessarily  being  preceded  by  an  acute  attack. 


CHRONIC   NEURITS.  819 

Cold  may  be  a  factor  in  its  causation,  and,  in  conjunction  with  damp, 
probably  produces  most  of  the  idiopathic  cases. 

Syphilis,  undoubtedly,  may  give  rise  to  chronic  neuritis.  I  am  quite 
sure  that  several  cases  having  this  origin  have  been  under  my  care — 
and  the  fact  is  admitted  by  Lagneau,1  Buzzard,3  ami  others. 

Diagnosis. — Chronic  neuritis  is  distinguished  from  progressive  mus- 
cular atrophy  mainly  by  the  circumstance  that  the  paralysis  pr< 
the  atrophy,  the  latter  being  a  secondary  condition,  while  in  progres- 
sive muscular  atrophy  it  is  the  primary  essential  phenomena.  The  pres- 
ence of  pain,  the  absence  of  fibrillary  contractions,  the  impairment  of 
the  electric  contractility,  and  the  existence  of  anaesthesia,  will  farther 
serve  to  make  the  diagnosis  exact.  Moreover,  the  clinical  history 
cannot  fail  to  add  to  the  distinctive  features  of  the  two  affections. 

From  neuralgia  it  is  diagnosticated  by  symptoms  and  characteris- 
tics to  which  attention  has  been  drawn  in  the  immediately  preceding 
chapter. 

Prognosis. — Mitchell  regards  the  prognosis  of  chronic  or  subacute 
neuritis  as  grave  in  proportion  to  the  length  of  nerve  involved,  and  the 
extent  to  which  the  morbid  process  has  traveled  in  a  central  direction. 
His  opinion  is  based  rather  upon  the  traumatic  variety  of  the  dis< 
than  the  idiopathic.  To  the  opinion  expressed  by  him  I  would  add  thai 
the  chronic  neuritis  which  results  from  central  lesions  is  particularly 
hopeless.    That  due  to  syphilis  is  not  generally  unamenable  to  treat  i 

Morbid  Anatomy  and  Pathology. — The  process  which  characterizes 
chronic  neuritis  is  not  essentially  different  from  that  which  marks  ohronio 
inflammatory  action  in  the  white  tissue  of  the  spinal  cord.  It  con 
in  a  hyperplasia  of  the  neuroglia  and  a  contemporaneous  at  rophy  of  the 
nerve-tubes.  The  white  substance  of  Schwann  undergoes  fatty  degen- 
eration, and  the  nerve-tubes  remain  as  dense  fibrous  cords.  The  mor- 
bid action,  therefore,  takes  on  the  features  of  sclerosis,  even  to  the  pro- 
duction of  the  characteristic  gray  coloration. 

The  main  points  in  the  pathology  of  the  aff<  otion  have  already  been 
mentioned,  and  need  not,  therefore,  be  again  considered. 

Treatment. — Except  in  the  ohronio  neuritis  due  to  syphilitic  infec- 
tion there  is  not  much  to  do  in  the  way  of  internal  medication.  En 
this  form  the  iodide  of  potassium,  given  in  gradually-increasing  I 

reviously  recommended  for  chronic  basilar  meningitis  of  lik 

is  necessary,  and  will  often,  if  the  disease  lias  not   advanced  too 

i   a  cure.     In  all  forma  the  primary  galvanic  ourrent,  "1"  as  greal  a 

ee  of  intensity  as  the  patient   can  bear,  should  be  applied  to  the 

aeons  surface  over  il"'  affected  nerve.     The  conducting  power  ol 

the  skin  should  be  increased  by  wetting  it,  and  the  electrodes  should  be 

uet  sponges.     If  the  nerve  i-  so  situated  as  noi  to  be  acted  upon  di 

'  "  ICaladiet  ■yphilitiqaes  'In  lyitfcme  nenreux,"  I 

'  "  clinic. ii  aspects  of  Syphilitic  v<  '  London,  1874,  p.  ~i 


820  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

rectly,  the  current  should  be  so  applied  as  to  affect  it  secondarily.  For 
instance,  the  third  nerve  may  be  subjected  to  the  galvanic  stimulus 
by  one  pole  being  placed  over  the  closed  eye,  and  the  other  on  the 
nape  of  the  neck.  The  same  process  answers  for  the  optic,  fourth,  and 
sixth  nerves.  Care  should  be  taken  to  use  a  current,  in  such  cases,  of 
low  tension;  and,  in  all  applications  of  the  primary  current  to  the  face, 
this  caution  should  be  remembered. 

For  the  jmralyzed  muscles,  the  procedure  recommended  in  the  pre- 
vious chapter  of  using  either  the  galvanic  or  faradaic  current,  or  both, 
as  the  case  may  appear  to  demand,  is  equally  applicable  to  chronic 
neuritis. 

Hypodermic  injections  of  strychnia  are  useful.  The  initial  dose 
may  be  about  one  twenty-fourth  of  a  grain,  and  this  may  be  gradually 
increased.  The  injection  should  be  made  at  a  point  as  near  to  the 
affected  nerve  as  may  be  possible  and  proper. 


CHAPTER  VI. 

TUMORS    OF  KEBVES. 

The  nerves,  like  the  brain  and  spinal  cord,  are  subject  to  morbid 
growths  ;  but  very  little  is  known  of  them  either  clinically  or  anatomi- 
cally. Gummy  tumors,  syphilitic  in  origin,  and  giving  rise  to  symp- 
toms not  essentially  different  from  those  just  described  as  characteriz- 
ing chronic  neuritis,  are  -known  to  exist.  The  following  case  from  Buz- 
zard '  was  probably  one  of  the  kind  in  question: 

"A  laborer,  aged  thirty-one,  applied  in  February,  1873,  with  paral- 
ysis of  the  right  lower  extremity  of  two  and  a  half  years'  standing. 
The  limb  was  greatly  wasted,  and  the  foot  could  not  be  moved  at  all. 
It  seemed  that  on  getting  up  one  morning  he  found  his  foot  useless. 
No  pain  had  preceded  or  followed  the  attack,  and  he  had  not  been  ill. 
Excitability  to  the  induced  current  was  lost  in  all  the  muscles  below 
the  knee,  and  very  much  diminished  in  the  muscles  at  the  back  of  the 
thigh,  while  it  remained  good  in  those  on  the  anterior  aspect  of  the 
thigh,  in  which  also  he  retained  voluntary  power.  The  sensibility  of 
the  skin  in  parts  corresponding  to  the  paralyzed  muscles  was  greatly 
diminished.  There  was  no  increased  excitability  to  the  intermitted 
constant  current.  The  seat  of  paralysis  corresponded  completely  with 
the  distribution  of  the  great  sciatic  nerve.  There  was  no  impairment 
of  the  functions  of  the  bladder,  nor  of  the  other  leg.  It  appeared  evi- 
dent that  there  was  a  lesion  of  the  sciatic  nerve  alone.  Although  he 
positively  denied  any  syphilitic  infection,  the  existence  of  a  very  ugly- 
looking  sore  on  the  right  leg  (suggestive  of  a  gummatous  ulceration), 

1  Op.  cit.,  p.  112. 


i  !:.\L  PARAL1  -  821 

which  he  bad  had  for  three  months,  made  it  likely  that  then  had  also 
been  a  gumma  of  the  sciatic  nerve,  an  1  he  was  accordingly  onl 
iodide  and  mercury.     Under  this  treatment  1 1 1  •  -  Bore  rapidly  healed,  he 
gained  a  certain  amount  of  power  in  the  leg,  and  he  described  bio 
as  feeling  more  than  usually  well  in  his  general  health,  but  in  April  he 
ceased  to  attend,  so  that  I  am  unable  to  give  the  sequel  of  his  o 

Virchow,1  while  admitting  that  the  nerves  may  be  the  seat  of  _ 
my  tumors,  declares  that  those  most  frequently  affected  are  the  optic, 
the  olfactory,  the  third,  fourth,  fifth,  and  sixth,      lie   refers  to   a 
cited  by  Zambaco,  in  which  the  crural  was  apparently  the  - 
gummy  tumor. 

Bi  .^ides  the  gummy  tumor,  nervea  are  subject  to  cancerous  tumors, 
tomyxomata,  and  to  various  forms  of  neuromata,  among  which  the  pain- 
ful tubercule  is  specially  to  be  mentioned.  These  Latter  are  small,  and 
generally  situated  just  under  the  skin. 

The  treatment  of  neurotic  tumors  is  not  medical  except  for  those 
which  are  of  syphilitic  origin.     For  these  the  iodide  of  potassium  and 
mercury  are  the  remedies  which  are  indicated.     All  others  require 
cision. 


CHAPTER  VII. 

NEURAL     PARALYSIS. 
i  U  i  w.    I'ai:  ULY8IS. 

I  'ak.u.ysis  of  t  he  facial  nerve  lias  already  beeu  considered  as  i  symp- 
tom of  several  central  lesions,  but  it  may  <-\ist  as  an  affection  of  alto- 
gether peripheral  origin.     As  such,  it  is  often  known  as  Bell's  pai 

•  u    account  of   its    real  nature  having  been  first  clearly  pointed  out 

by  Sir  Charles  Bell.     The  nerve  in  question,  the  facial  or  portio  dura 

of  the  seventh  pair,  was  formerly  regarded  as  oi i  sensation,  and, 

in  accordance  with  this  new,  was  often  divided  for  neuralgia.  The 
experiments  of  Bell  and  Magendie  established  the  fact  of  its  being  en- 
tirely a  nerve  of  Hi.  .I  ion. 

Symptoms. — 'The  facial  nerve  is  distributed  to  nearly  every  m 
te  face.     It a  paralysis  therefore  causes  suoh  decided  chanj 
pression  as  to  be  readily  recognizable.      The  most  marked  phenomi 
and  one  which  is  of  importance  in  the  diagnosis,  is  the  inability 
the  eye  of  th  d  side.     This  is  due  to  the  fact  thai  the  orbioul 

palpebrarum  has  ontraotile  power,  while  the  levator  palpi 

luperioris,  nol  supplied  by  the  facial, but  by  the  third  nei  par- 

alyzed, and  keeps  the  upper  lid  elevated,     I  this  con- 

dition, the  eye  is  oonstantlj  exposed  to  the  action  of  the  atmosphere, 

Pathol  •"''  nch  edition,  I  •   ' 


822  DISEASES   OF  THE   PERIPHERAL   NERVOUS   SYSTEM. 

and  to  contact  with  extraneous  substances.  The  patient  cannot  wink, 
and  thus  the  tears,  not  being  distributed  over  the  surface  of  the  eyeball 
or  carried  off  by  the  nasal  duct — the  tensor  tarsi  also  being  paralyzed 
— run  over  the  lower  lid,  and  scald  the  cheek.  From  this  inability  to 
wink,  dust  and  other  small  particles  of  matter  are  not  removed,  and 
hence  considerable  irritation  is  produced.  Exposure  to  strong  light  or 
to  wind  adds  to  the  inconvenience.  Comparative  comfort  may  be  ob- 
tained by  the  patient  frequently  closing  the  eye  with  the  finger,  or  by 
keeping  the  lids  together  with  a  piece  of  adhesive  plaster. 

The  next  most  prominent  group  of  symptoms  is  due  to  the  loss  of 
power  in  one  lateral  half  of  the  orbicularis  oris.  As  a  consequence, 
the  patient  cannot  purse  up  the  mouth  on  that  side,  as  in  the  act  of 
whistling  or  spitting.  From  this  loss  of  tonicity  the  saliva  is  not  re- 
tained on  the  affected  side  of  the  mouth,  but  runs  out  over  the  lip,  to 
the  great  annoyance  of  the  patient. 

The  muscles  of  mastication,  the  masseter,  temporal,  and  external 
and  internal  pterygoid,  are  supplied  by  the  third  branch  of  the  fifth 
pair  of  nerves,  and  hence  the  ability  to  chew  is  not  impaired.  The 
buccinator,  the  function  of  which,  in  conjunction  with  the  tongue,  is  to 
press  the  alimentary  bolus  against  the  jaws,  and  thus  keep  it  submitted 
to  their  action,  is  supplied  by  the  facial,  and  hence  its  office  is  not  per- 
formed. The  food  consequently  accumulates  between  the  jaws  and  the 
cheek,  and  it  must  be  continually  removed  by  the  finger. 

The  muscles  which  expand  the  face,  as  in  the  action  of  laughing  or 
smiling,  are  supplied  by  the  facial,  and  their  paralysis  destroys  the  nor- 
mal equilibrium,  and  hence  the  face  is  drawn  toward  the  sound  side. 
This  loss  of  antagonism  is  most  evident  when  the  patient  opens  his 
mouth,  and  particularly  when  he  laughs  or  smiles,  for  the  paralyzed 
muscles,  the  zygomatici,  and  the  risorius,  are  incapable  of  responding 
to  the  emotion,  while  those  on  the  sound  side  contract  vigorously. 

The  paralysis  of  the  occipito-frontalis  and  of  the  corrugator  super- 
cilii  prevents  the  raising  of  the  eyebrows,  or  frowning,  and  obliterates 
all  wrinkles  from  the  brow.  As  Romberg  remarks,  there  is  no  better 
cosmetic  for  elderly  ladies  than  facial  paralysis  ("  fur  alte  Frauen  kein 
wirksameres  Cosmeticum  existirt"). 

Among  other  symptoms,  it  is  noticed  that  the  ala  nasi  is  depressed, 
and  does  not  expand  as  air  is  drawn  in  through  the  nostril,  and  that 
the  articulation,  especially  of  words  containing  labials,  is  indistinct. 

The  expression  of  one  side  of  the  face  is  therefore  destroj^ed  ;  it  is 
a  complete  blank,  incapable  of  responding  to  any  emotion,  and  unable 
to  execute  those  movements  which  in  the  normal  condition  are  per- 
formed by  its  muscles.  The  muscles  soon  begin  to  lose  their  electrical 
excitability,  and  in  a  short  time,  if  recovery  is  delayed,  the  electrical 
degenerative  reactions  (see  page  28)  can  be  perfectly  demonstrated. 

Such  are  the  obvious  and  superficial  symptoms  of  an  ordinary  attack 


NEURAL  PARALYS 

of  unilateral  facial  paralysis.     For  the  full  understanding  of  other  im- 
portant phenomena,  a  few  words  in  relation  to  the  anatomy  and  pa 
ology  of  the  nerve  are  necessary. 

The  facial  nerve  takes  its  origin  from  the  posterior  border  of  the 
pons  Varolii  and  the  lateral  tract  of  the  medulla  oblongata.  Some  of 
its  fibres  of  origin  may  be  traced  to  the  floor  of  the  fourth  ventri 
and  even  to  the  lateral  columns  of  the  spinal  cord.  A  knowledge  of  its 
course  and  connections  enables  us  to  determine  with  a  good  deal  of  ac- 
curacy the  seat  of  the  lesion  by  which  it  is  paralyzed,  and  thus  we  have 
;tn  important  element  in  making  a  pi 

From  its  point  of  apparent  origin  the  facial  :  rward  and  out- 

ward, resting  on  the  crus  cerelxlli,  and  leaves  the  cranial  cavity  by 
entering  the  internal  auditory  meatus  with  the-  auditory  nerve.  It  i 
enters  the  aqueduetus  Fallopii,  and,  passing  through  its  whole  length, 
makes  its  exit  from  the  skull  by  the  stylo-mastoid  foramen;  while  in 
the  aqueduetus  Fallopii  it  gives  off  three  branches,  the  two  superficial 
petrosal  nerves,  and  the  chorda  tympani.  The  greaf  superficial  p 
sal  passes  to  Meckel's  ganglion,  and  through  this  supplies  the  levator 
palati  and  the  azygos  uvuke  muscles;  th<'  small  superficial  petrosal — 
regarded  by  some  as  a  branch  of  the  glossopharyngeal,  though  com- 
municating with  the  facial — runs  to  the  otic  ganglion  which  BUpplies 
the  tensor-palati  and  tensor-tympani  muscles,  and  also,  according  to 
Bernard,  presides  over  the  secretion  of  the  parotid  gland,  through  the 
auriculo-temporal  nerve;  the  chorda  tympani  goes  to  join  the  gustatory 
branch  of  the  fifth,  and  is  in  part  distributed  with  this  to  the  tongue, 
but  another  portion  of  its  fibres  enters  the  submaxillary  ganglion  which 

ides  over  the  function  of  the  submaxillary  gland. 

With  this  brief  rkaumt   of  the  anatomical  and  physiological  points 
of  the  facial  nerve,  we  are  prepared  t<>  study  other  symptoms  to  which 
I  have  not  as  yet  alluded;  for,  in  the  account  given,  1  have  simply 
aidered  the  phenomena  of  faoial  paralysis  when  the  lesion  is  situated  on 

the   distal    side   of   the   sty  lo-mastoid  foramen.      But    the    nerve   may  be 

affected  farther  back,  and,  though  in  such  a  case  we  have  the  symptoms 
already  described,  there  are  others  which  vary  aooording  to  the  seat  ol 

the  ili  -ease. 

Thus,  if  the  morbid  prooess  is  iii  action  above  the  origin  of  the 
chorda  tympani,  but  below  that  of  the  petrosal  nerves,  the  patient  will 
experience  a  diminution  but  not  a  complete  abolition  of  the  sense  ol 
taste  upon  the  corresponding  side  of  the  tongue.  This  fad  led  to  the 
supposition  that  Che  ohorda  tympani  was  a  sensitive  nerve,  but  th. 
perimenta  of  Bernard  and  others  bave  clearly  shown  that  it  is  an  effer- 
ent nerve,  oonveying  influence  from  the  brain,  not  to  it.  <  me  of  its 
actions  is  to  increase  the  flow  of  submaxillary  saliva,  [n  addition,  h 
supplies  the  lingualis  muscle,  and  probabl]  the  papilla  of  the 

tongue,  and  modifies  the  circulation  of  this  organ.     When,  therefoi 


824  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

lesion  of  the  facial  exists  above  the  origin  of  the  chorda  tympani,  the 
sense  of  taste  on  that  side  is  lessened  because  the  dryness  of  the  mouth 
prevents  the  ready  solution  of  the  sapid  substance.  The  difficulty  is 
augmented  through  the  non-erection  of  the  papillas,  and  perhaps,  also, 
by  the  change  which  has  ensued  in  the  circulation.  This  diminution  of 
the  sense  of  taste  therefore  shows  that  the  lesion  is  seated  on  the  cen- 
tral side  of  the  origin  of  the  chorda  tympani  nerve. 

Again,  if  the  lesion  be  situated  behind  the  gangliform  enlarge- 
ment, from  which  the  petrosal  nerves  arise,  but  anterior  to  the  meatus 
internus,  we  have,  of  course,  all  the  symptoms  mentioned,  and  in  addi- 
tion those  due  to  paralysis  of  the  petrosal.  One  of  them  is  the  depres- 
sion of  the  palatine  arch  on  the  affected  side  ;  it  hangs  lower  than  the 
opposite  one,  and  its  edge  is  nearly  straight  instead  of  curved.  This 
condition  results  from  paralysis  of  the  levator-palati  muscle,  which,  as 
we  have  seen,  is  supplied  by  the  great  petrosal  through  Meckel's  gan- 
glion. One  of  the  two  little  muscles  of  the  uvula  being  powerless,  the 
other  draws  the  uvula  into  a  bow  shape,  with  the  concavity  toward  the 
sound  side.  The  uvula  and  the  velum  are  also  pulled  en  masse  toward 
the  sound  side  by  the  action  of  the  tensor  palati,  the  other  being  para- 
lyzed through  the  implication  of  the  small  petrosal  nerve.  The  connec- 
tion of  the  small  petrosal  through  the  otic  ganglion  with  the  parotid 
gland  causes  a  diminution  of  the  secretion  of  this  gland  when  the  lesion 
of  the  facial  is  in  the  situation  described. 

Acuteness  of  hearing  on  the  paralyzed  side  is  sometimes  observed, 
This  is  accounted  for  by  Landouzy,1  on  the  ground  of  the  paralysis  of 
the  tensor-tympani  muscle,  which,  as  we  have  seen,  is  supplied  by  the 
otic  ganglion,  but  Brown-S6quard  attributes  it  to  hyperesthesia  of  the 
acoustic  nerve  from  vaso-motor  spasm. 

This  last  category  of  symptoms,  therefore,  indicates  the  seat  of  the 
lesion  to  be  at  or  behind  the  gangliform  enlargement. 

When  the  lesion  is  within  the  cranium,  we  have  all  the  symptoms 
mentioned,  but  they  are  complicated  with  others  indicative  of  derange- 
ments of  other  nerves,  or  of  cerebral  disease.  These  have  already  been 
considered  under  other  heads. 

In  the  foregoing  account  of  facial  paralysis,  the  unilateral  form, 
which  is  by  far  the  most  common,  has  alone  been  considered,  but  both 
nerves  may  be  paralyzed,  producing  what  is  called  double  facial  paraly- 
sis, or  facial  diplegia.  The  condition  has  been  well  described,  among 
others,  by  Wachsmuth,2  and  by  Pierreson,3  the  latter  of  whom  has  col- 
lected twenty-eight  cases  as  the  basis  of  his  memoir.  Both  sides  may 
be  paralyzed  simultaneously,  in  which  instance  the  disease  is  probably 
central,  or  one  may  follow  the  other.     In  either  case,  the  face  presents 

1  "  De  r"alt6ration  de  l'ou'i'e  dans  la  paralysie  faciale,"  Gazette  Medicale,  Paris,  1851- 
e  "  Ueber  progressive  Bulbar-Paralj  se  und  die  Diplegia  facialis,"  Dorpat,  1864. 
3  "De  la  diplegie  faciale,"  Archives  9enerahs  3fedecine,  Aout,  1867,  p.  139. 


NEURAL   PARALYSIS.  825 

a  complete  want  of  expression,  and  the  symptoms  previously  mentioned 
are  duplicated  in  full.  Two  excellent  representations  of  the  affection 
are  given  in  the  report  of  a  case  by  Mr.  Wright.1  Only  one  case  has 
come  under  my  observation.  It  was  of  long  standing  and  incurable. 
I  lost  sight  of  the  patient  before  I  could  have  his  photograph  taken. 

Causes. — Cold  is  a  prominent  cause  of  facial  paralysis.  It  is  most 
apt  to  induce  that  form  of  the  disease  in  which  the  lesion  is  external  to 
the  temporal  bone.  Exposure  to  intense  cold,  especially  when  the  wind 
was  blowing,  has  caused  several  cases  in  my  experience.  The  patient 
has  gone  to  bed  feeling  pretty  well,  and  has  awakened  with  one  side  of 
the  face  paralyzed. 

Rheumatic  inflammation,  occurring  in  the  course  of  the  nerve,  may 
also  induce  facial  paralysis,  as  may  likewise  tumors  of  the  parotid  gland, 
or  other  cause  capable  of  making  pressure  on  the  nerve.  I  have  seen 
several  cases  which  had  resulted  from  sleeping  with  the  closed  hand 
under  the  face;  and  it  may  occur  in  new-born  children,  as  the  result  of 
pressure  by  the  forceps.  AVounds  and  injuries  of  other  kinds  may,  of 
course,  produce  it. 

Within  the  temporal  bone,  facial  paralysis  may  result  from  tumors, 
from  periostitis,  from  caries  of  the  petrous  portion  of  the  temporal 
bone,  from  disease  of  the  middle  ear,  from  haemorrhage  into  the  aque- 
ductus  Fallopii,  and  from  fractures  of  the  temporal  bone. 

Within  the  cranium  it  may  be  caused  by  disease  of  the  pons  Va- 
rolii, or  of  the  medulla  oblongata,  by  atrophy  of  the  nerve,  by  tumors, 
and  as  the  consequence  of  injury.  These  latter  do  not,  however,  de- 
mand our  notice,  as  they  have  already  been  considered  in  other  connec- 
tions. 

Diagnosis. — Facial  paralysis  is  distinguished  from  glosso-labio-laryn- 
geal  paral}*sis,  by  the  facts  that  in  the  latter  the  symptoms  affect  only 
the  lower  part  of  the  face,  and  that  they  are  accompanied  by  paralysis 
of  the  tongue  and  of  the  muscles  of  deglutition.  From  the  facial  pa- 
ralysis of  hemiplegia  it  is  diagnosticated  by  the  marked  oircumstanoi 
that,  in  the  latter  disorder,  the  patient  can  close  the  eye,  while  in  the 
former  it  remains  wide  open.  There  are  no  other  affections  with  which 
facial  paralysis  can  be  confounded,  if  the  slightest  attention  be  given 
to  its  symptoms. 

Prognosis. — The  prognosis  varies  according  to  the  seat  and  the 
cause  of  the  lesion,  and  the  duration  of  the  paralysis.  If  this  latter  is 
due  to  cerebral  or  intra-cranial  lesion,  or  to  disease  existing  within  the 
aqucductus  Fallopii,  the  prospect  of  cure  is  remote.  But,  if  the  lesion 
exists  ou<  Bide  of  the  skull,  and  is  capable  of  removal,  or  it'  the  paralysis 
be  the  result  of  exposure  to  cold,  or  subjection  to  pressure,  and  it'  the 
electric  contractility  of  the  muscles  be  oot  destroyed,  the  case,  under 
suitable  treatment,  will  probably   terminate   favorably.      By  electric 

1  "  Nbtea  of  a  Case  of  Double  Facial  Palsy,"  British  Medical 


826  DISEASES   OF   TIIE   TERIPIIERAL   NERVOUS   SYSTEM. 

contractility,  I  do  not  mean  the  ability  to  respond  to  the  excitation  of 
the  induced  current,  for  this  is  lost  at  an  early  period  in  the  majority 
of  cases,  but  to  contract  upon  the  application  of  as  strong  a  primary 
current  as  can  with  safety  be  applied  to  the  face. 

In  deep-seated  lesions,  if  a  clinical  history  of  syphilis  can  be  made 
out,  the  prognosis  becomes  more  favorable. 

If  the  affection  has  lasted  a  long  time,  and  if  contractions  of  the 
paralyzed  muscles  from  atrophy  have  taken  place,  the  probability  of 
recovery  is  very  slight,  even  if  there  is  some  glimmering  of  electro- 
contractility. 

Morbid  Anatomy  and  Pathology. — When   facial  paralysis  results 

from  cold,  it  may  be  from  consequent  neuritis,  or  from  inflammation 
excited  in  contiguous  parts.  In  the  latter  case  lymph  is  effused  and 
pressure  is  exerted  upon  the  nerve.  JUost  of  the  other  causes  act  by 
the  pressure  they  make  on  the  nerve,  and;  though,  as  in  the  case  of 
sleeping  with  the  list  under  the  face,  the  action  may  not  be  long  con- 
tinued, the  consequence  is  very  lasting.  The  effects  of  pressure  upon 
a  nerve  are  experienced  when  we  sit  too  long  in  one  position,  so  as  to 
compress  the  sciatic  nerve,  or  when  persons  go  to  sleep  with  one  arm 
thrown  over  the  back  of  the  chair  on  which  they  are  sitting.  The  axil- 
lary plexus  is  compressed,  and  paralysis,  more  or  less  complete,  of  the 
muscles  supplied  by  it,  is  the  result.  Several  such  cases  have  come 
under  my  observation,  and  the  resulting  paralysis  is  generally  most  dif- 
ficult to  remove. 

The  fact  that  in  the  affection  now  under  notice  the  orbicularis  pal- 
pebrarum is  paralyzed,  while  in  facial  paralysis,  symptomatic  of  cere- 
bral disease,  such  as  hasmorrhage,  it  escapes,  is  to  be  explained  by  the 
circumstance  that  in  the  latter  disease  all  the  fibres  of  origin  of  the 
nerve  are  not  involved,  while  in  the  former  the  whole  trunk  of  the 
nerve  is  subjected  to  the  morbid  process,  and  hence  all  the  muscles 
which  it  supplies  are  paralyzed. 

Treatment. — The  indications  are  :  to  remove  the  cause  if  possible  ; 
to  put  the  nerve  under  the  best  possible  conditions  for  regaining  its 
lost  power;  and  to  preserve  the  organic  integrity  and  irritability  of  the 
muscles  till  this  can  take  place.  When  there  is  reason  to  suspect  the 
existence  of  a  syphilitic  taint,  and  the  growth  of  exostoses  of  syphi- 
litic character  in  the  aqueductus  Fallopii,  the  iodide  of  potassium  with 
the  bichloride  of  mercury  should  be  given,  according  to  the  formula  on 
page  313.  In  several  cases  I  have  succeeded  in  effecting  cures  by  this 
treatment,  conjoined  with  electricity,  when  the  latter  by  itself  had  pro- 
duced no  improvement,  or  the  iodide  may  be  given  alone  in  gradually- 
increasing  doses,  as  recommended  for  chronic  basilar  meningitis. 

For  the  restoration  of  the  nerve-function,  we  can  do  little  beyond 
securing  healthy  nutrition  of  the  general  system,  by  the  use  of  proper 
hygiene  and  tonics'.     Among  the   latter,  strychnia  is  especially  useful. 


NEURAL    I'AKAL 

It  should  be  employed  persistently  and  in  gradually  increasi] 
till  some  evidence  of  its  physiolog  For  this 

purpose  I  make  use  of  a  solution  of  the  Bulphal  ychnia  in  the 

proportion  of  one  grain  to  the  ounce  of  wato  r.     Every  ton  minimi 
such  a  solution  contain  ^g  of  a  grain   of  the  medio  oerally  I 

:i  with  ten  minims  of  this  solution  three  tin*  -  a  day  for  tin-  tii-t 
day  ;  tin-  next  day  eleven  minims  are  given  three  times  :  the  next 
twelve,  ami  so  on,  till  the  patient  experieni  ition  "i  cramp  or 

rigidity  in  the  legs,  or  in  muscles  of  the  hack  of  tin-  neck  <>r  of  tin- 
jaw.  Usually  the  cramp  i-  first  felt  in  the  calves  of  the  legs.  The 
farther  administration  is  now  stopped,  and,  if  ..  on  the  fol- 

lowing day  the  solution  i>  given  a-  before,  in  doses  of  ten  minims,  ami 
the  doses  are  again  run  up  to  the  extent  of  producing  tin-  muscular 
•  •ramp.     As  illustrative  of  the  action  of  this  method,  I  cite  the  fol 
ing  case  from  my  note-book.     It    i-  one  of  twenty-eight  others  in 
which  the  practice  referred  to  was  adopted. 

Miss  S.,  in  coming  from  Newark  to  New  York,  on  the  evening  of 
January.").  1878,  opened  the  oar  window  over  the  seat  on  which  she 
sat.  She  experienced  no  inconvenience  till  the  following  morning, 
when  on  awaking  she  found  that  the  left  side  of  the  face  was  par- 
alyzed. On  the  7th  she  came  under  my  observation.  Examination 
showed  that  not  only  were  all  the  muscles  of  the  face  supplied  by  the 
facial  nerve  paralyzed,  but  that  there  was  a  diminution  of  the  Bensi 
taste  on  the  Bi  le  of  the  tongue  corresponding  to  the  paralyzed  side  of 
the  face,  thai  the  left  palatine  arch  was  straighter  and  lower  than  the 
right,  and  that  the  uvula  was  concave  toward  the  paralyzed  Bide, 
while  this  organ  and  the  velum  were  drawn  over  toward  the  sound 
side.  These  phenomena  indicated  thai  the  lesion  or  morbid  pr< 
situated  behind  the  gangliform  enlargement. 

I  al  once  began  the  administration  of  the  strychnia,  according  to 
the  formula  just  given,  placed  the  hook  (to  be  more  specifically  men- 
tioned directly)  in  the  angle  of  the  mouth  on  the  left  side,  and  adi 
the  use  of  the  faradaic  current  for  a  few  minutes  every  alternate  day. 
On  the  tenth  day,  while  taking  the  J,  grain  of  the  strychnia,  she  felt 
a  little  rigidity  of  the  muscles  of  the  calves  of  the  legs.     It  wai 
slight,  how  ever,  that  i  advised  the  continuance  of  the  increasing  d 
Bui  even  now  the  improvement  was  evident,     she  could  close  th< 
of  the  affected  ride,  elevate  and  corrugate  the  brows,  and  Blightl)  re- 

■  the  angle  of  the  month.     When  she  laughed,  however,  the  right 

angle  of  the  mouth  was  retracted  much  farther  than  the  left. 

Bui  soon  alter  taking  the  third  dose  of  twenty-one  minis 

the   following   day,  she   experienced  very   decided   cramps   in   both 

which,  however,    passed  off    in    less   than    half   an   hour.     <  »n 

the  nexl   morning   I  saw  her.     The  action  of  the  facial  muscles  was, 

so  far  as  I  could   Bee,  equal  on  both  Bides.     There  was  no  relapse.1 

1  "  On  an  Improred  Method  of  Treating  Pacta!  Paralyal  . 

Mr,       | 


828  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

I  have  never  found  blisters  or  liniments  to  be  of  the  slightest  ser- 
vice. 

The  third  indication  is  to  be  met  by  passive  exercise,  such  as  can  be 
produced  by  pinching  and  kneading  the  muscles,  and,  above  all,  by  the 
persistent  use  of  electricity.  Without  this  latter  agent  facial  paralysis 
cannot  be  cured. 

If  the  induced  current  will  cause  the  muscles  to  contract,  it  should 
be  employed.  One  pole  is  placed  over  the  nerve  at  its  exit  from  the 
stylo-mastoid  foramen,  and  the  muscles  of  the  paralyzed  side  are  sep- 
arately excited  by  the  other.  A  seance  should  last  about  fifteen 
minutes,  and  should  be  repeated  every  alternate  day,  or  every  day  in 
bad  cases. 

If  the  induced  current  will  not  cause  contractions,  the  primary  in- 
terrupted current  should  be  used  for  the  purpose.  Care  should  be  taken 
not  to  employ  a  current  of  too  great  a  degree  of  intensity,  as  serious 
consequences  have  resulted  to  the  vision  by  neglect  of  this  precaution. 
As  a  rule,  three  or  four  milliamperes  will  be  sufficient.  Means  must 
be  taken  to  interrupt  the  current,  as  contractions  are  only  produced 
when  the  circuit  is  closed  and  opened,  but  if  the  interruptions  produce 
vertigo  the  strength  of  the  current  must  be  diminished.  When  the 
primary  current  has  been  employed  for  a  few  weeks,  it  will  generally 
be  found  that  the  induced  will  cause  the  muscles  to  contract,  in  which 
case  it  should  be  substituted. 

The  first  muscle  to  recover  power  is  usually  the  orbicularis  palpe- 
brarum, but  several  weeks,  and  sometimes  months,  are  requisite  to 
bring  about  a  complete  cure. 

As  an  additional  measure,  which  is  serviceable  iu  restoring  the 
muscles  of  the  mouth,  the  use  of  a  very  simple  apparatus  calculated  to 
relax  them  is  to  be  recommended.  It  consists  of  a  hook  made  of  hard 
rubber  or  whalebone,  or  some  other  suitable  substance,  which  is  caught 
into  the  angle  of  the  mouth  on  the  paralyzed  side,  and  then  attached 
to  the  corresponding  ear  by  means  of  an  elastic  band.  The  first  to  use 
such  an  appliance,  so  far  as  my  knowledge  extends,  was  Dr.  William 
Detmold,1  of  this  city,  who,  in  an  old  case  of  facial  paralysis,  obtained 
great  benefit  from  its  application.  His  apparatus  consisted  of  a  piece 
of  silver  wire  bent  into  a  hook  at  one  end,  for  the  angle  of  the  mouth, 
and  then  bent  again  at  the  other  end,  and  carried  over  the  top  of  the 
ear  somewhat  after  the  manner  of  a  pair  of  spectacles.  The  elastic 
band,  such  as  is  used  to  keep  letters  together,  is,  I  think,  an  improve- 
ment. 

PARALYSIS    OF   THE    THIRD    NERVE MOTOR    OCULI. 

Symptoms. — The  motor-oculi  nerve  which  supplies  the  upper  eyelid, 
the  superior,  inferior,  and  internal  recti  muscles,  the  inferior  oblique,  and 

1  "  Facial  Paralysis  treated  by  a  New  Method,"  New  York  Medical  Journal,  May,  1873, 
p.  491. 


XIXILU    PARAL1 

indirectly,  through  the  ophthalmic  ganglion,  the  circular,  or  constrict- 
ing fibres  of  the  iris,  has  already  b<  ered  in  its  central  patholo- 
gical relations.  It  is,  however,  the  s>-at  of  peripheral  disease,  either 
intrinsic  or  as  a  consequence  of  lesion  of  the  contiguous  tissues.  When 
the  trunk  of  the  nerve  is  the  seat  of  disease  or  subjected  to  pressure,  the 
symptoms  consist  of  ptosis  or  a  drooping  of  the  upper  eyelid,  externa] 
strabismus  from  the  action  of  the  uncompensated  externa]  rectus  mus- 
cle, and  dilatation  of  the  pupil  from  the  uncompensated  action  of  the 
dilator  pupilaris  muscle. 

The  patient,  therefore,  presents  a  remarkable  inoe.     The  up- 

per eyelid  hangs  down  over  the  cornea,  almost  but  not  quite,  in  exti 
cases  touching  the  lower  lid  ;  the  eyeball  is  turned  outward,  and,  from 
the  destruction  of  the  parallelism  of  the  axes,  double  vision  is  pro< i 
and  the  pupil  is  more  or  less  widely  dilated  and  insensible  to  the  stimu- 
lus of  light. 

The  external  rectus  and  the  .superior  oblique  of  all  the  extrinsic 
muscles  of  the  eyeball  remain  unpsralyzed,  bul  as  all  the  antagonizing 
muscles  are  powerless,  they  are  in  it  state  of  tonio  contraction,  and  the 
mobility  of  the  eye  fa  hence  destroyed. 

Generally,  however,  in  peripheral  paralysis  of  the  third  nerve,  the 
muscles  most  frequently  affected  are  the  levator  palpebral  superioris, 
or  the  internal  rectus,  or  both  ;  and  the  branches  supplying  these  I 
are  therefore  alone  involved. 

Gases  of  the  kind  are  not  uncommon.     An  interesting  ease  came 
under  my  observation  not  long  since  in  consultation  with  Drs,  T.  B. 
Sterling  and  T.  C.  Finnell.     Recovery  took  place  under  suitable  treat 
mint,  but,  some  six  months  afterward,  the  patient,  a  boy,  about  twelve 
years  old,  was  brought  to  me  by  his  mother  on  account  of  a  recuro 
A  cure  was  again  easily  effected.     In  this  case  the  disease  was  appar- 
ently the  result  of  reflex  action  from  the  stomach.     The  regulation  of 
the  diet,  the  internal  use  of  strychnia,  and  the  application  of  the  ' 
daic  current   to  the  closed  eye  in  both  instances  relieved  the  condition 
in  a  couple  of  weeks. 

Causes. — Peripheral  paralysis  of  the  third  nerve  may  lie  induce. 1  by 

syphilitic  or  other  tumors  compressing  the  nerve,  by  rheumatic  exuda- 
tions along  its  course  acting  in  like  manm  r,  by  blows  upon  the  eyeball, 
or  by  other  injuries  ;  by  currents  of  cold  air  blowing  upon  t1 

by  refles  irritations,  such  BS  indigestible  f 1  or  worms  in  the  aliment- 
ary canal.     The  two  latter  are  especially  active  oauat  s  in  children. 

Diagnosis. — From  central  disease  peripheral  paralysis  of  the  motor 
oouli   nerve  is  readily  distinguished   by  the  absence  of  "head-symp 

tollis." 

Prognosis. — This  depends  very  much  upon  the  cause,     if  the  paral- 
results  from  pressure  it  will  continue  so  long  u  the  factor  n  n 

,n  operation.      Syphilitic  tumors  are  more  readily  removed  by  coiistiti! 


830  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

tional  treatment  than  any  others.  These  latter  may,  however,  in  some, 
cases,  be  gotten  rid  of  by  surgical  operation.  When  the  affection  is 
induced  by  wounds  or  injuries,  recovery  is  probable  unless  the  structure 
of  the  nerve  has  been  seriously  impaired.  When  it  is  caused  by  cold, 
rheumatic  exudations,  or  reflex  irritations,  recovery  is  the  rule. 

The  Morbid  Anatomy  and  Pathology  scarcely  call  for  any  additional 
remarks  ;  and  the  Treatment  is  to  be  conducted  upon  the  same  princi- 
ples as  those  laid  down  for  facial  paralysis.  It  is,  however,  worthy  of 
special  mention  that  the  tension  may  be  advantageously  taken  from  the 
muscle  of  the  upper  eyelid  by  the  use  of  a  thin  piece  of  India-rubber, 
which  is  to  be  attached  to  the  lid  and  to  the  skin  above  it  by  collodion, 
as  recommended  by  Dr.  John  Van  Bibber,  of  Baltimore. 

Division  of  the  external  rectus  may,  in  old  cases,  be  necessary  for 
the  obviation  of  the  strabismus. 

Paralysis  of  the  sixth  or,  abducens  nerve,  by  which  the  eye,  owing 
to  the  loss  of  power  in  the  external  rectus  and  the  uncompensated  ac- 
tion of  the  internal  rectus,  is  turned  inward  and  double  vision  produced, 
has  a  like  clinical  history,  and  is  to  be  treated  upon  like  principles. 

The  same  may  be  said  mutatis  muta?idis  of  other  peripheral  paraly- 
ses, as,  for  instance,  of  the  muscles  of  the  larynx,  of  the  deltoid,  and  of 
the  muscles  supplied  by  the  radial  nerve. 

Relative  to  this  latter,  the  radial,  M.  Panas  1  has  shown  that  the 
paralysis  to  which  it  is  liable  is  not,  as  generally  supposed,  the  result 
of  cold,  but  of  slight  pressure,  to  which  it  is  often  subjected,  and  M. 
Desplats  a  adduces  additional  arguments  in  support  of  this  view. 

The  latter  cites  the  following  case,  the  details  of  which  were  given 
to  him  orally  by  MM.  Panas  and  Raynaud: 

In  1874  there  was  in  the  wards  of  M.  Raynaud,  at  the  Lariboisiere, 
a  patient  affected  with  phthisis,  and  who  was  suddenly  one  night  taken 
with  paralysis  of  the  left  radial  nerve.  At  the  morning  visit  the  fact 
was  noticed  and  the  cause  sought  for.  The  patient  habitually  slept  on 
the  right  side,  and  the  idea  of  compression  was  therefore  dismissed,  the 
paralysis  being  attributed  to  cold.  But  a  neighboring  patient  stated  that 
he  had  seen  the  paralyzed  man  sleeping  with  his  left  arm  lying  on  the 
table  by  the  side  of  his  bed,  and  his  head  resting  on  it.  This  satisfac- 
torily accounted  for  the  paralysis.  In  the  course  of  a  few  days  it  was 
cured  by  electrization.     But  a  few  days  afterward  the  patient  died. 

The  post-mortem  examination  of  the  nerve  was  made  with  great 
care  by  MM.  Panas  and  Raynaud,  and  they  both  remarked  that  at  the 
point  where  the  compression  had  been  made  the  nerve  was  of  a  very 
decided  ochrey  color.     The  portion  thought  to  be  injured  was  examined 

1  "  De  la  paralysie  reputee  rheumatismale  du  nerf  raiial,"  Archives  Generates  d< 
Medecine,  16*73,  p.  65*7. 

9-  "Des  paralysies  p6ripheriques,"  Paris,  1875,  p.  61. 


NEURAL    SPASM.  831 

in  the  laboratory  of  the  College  of  France,  but  no  further  alteration  was 
detected.  This  was  not  remarkable,  as  the  functions  of  the  nerve  had 
been  restored  for  several  days. 


CHAPTER  VIII. 

XEUBAL    SPASM. 

There  are  two  affections  which  may  be  taken  as  the  types  of  pe- 
ripheral spasm  in  general :  these  are  spasm  of  the  facial  muscles — the 
mimic  or  histrionic  spasm  of  Romberg,  the  convulsive  tic  of  the  French 
— and  torticollis,  or  the  spasm  in  the  muscles  of  the  neck  supplied  by 
the  spinal  accessory  nerve. 

FACIAL     SPASM. 

The  spasms  in  the  disease  under  notice  may  be  either  clonic  or  tonic, 
the  former  being  by  far  the  more  common.  In  the  clonic  form,  the 
muscles  of  the  face,  or  a  portion  of  them,  generally  on  one  side,  are 
suddenly  and  violently  contracted,  and.  as  suddenly  relaxed.  Some- 
times, the  angle  of  the  mouth  is  drawn  back;  again,  the  upper  lip  and 
the  alas  of  the  nose  are  elevated  ;  and  again,  the  spasm  affects  the  or- 
bicularis palpebrarum.  In  a  case  formerly  under  my  charge,  occurring 
in  a  gentleman  from  Rahway,  New  Jersey,  both  orbicularis  muscles 
were  affected  with  clonic  and  tonic  spasms,  the  eyes  sometimes  bein<_r 
closed  for  several  minutes  at  a  time. 

The  spasms  come  on  in  paroxysms  which  are  of  variable  duration. 
I  have  seen  them  last  continuously  for  over  an  hour.  Generally,  they 
continue  from  a  few  seconds  to  one  or  two  minutes,  and  are  repeated 
at  intervals  of  about  the  same  time.  They  may  generally  be  excited  by 
emotional  disturbance  of  any  kind  ;  by  muscular  exertion,  by  a  current 
of  wind,  or  other  cause  capable  of  exciting  reflex  actions.  In  the  case 
above  referred  to,  they  are  always  induced  by  walking.  They  oan  •" 
made  to  cease  by  pressure  upon  the  facial  nerve  at  various  points,  and 
they  are  generally  arrested  by  powerful  mental  occupation  and  by 
sleep. 

In  the  tonic  form  of  the  affection  the  spasm  persists,  ami  causes 
more  or  less  distortion  of  the  face.  It  interferes  with  articulation,  mas- 
tication, and  especially  with  emotional  expression. 

The  tendency  is  for  cither  form  to  become  habitual,  and  hence  to 
he  difficult  of  cure. 

Causes. — Cold  is  a  common  cause,  as  are  also  wounds  and  injuries, 
and  carious  teeth.  I  have  seen  tw«>  cases  recently,  from  this  last-named 
in  11  uence. 


832  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

The  Diagnosis  calls  for  no  special  consideration,  and  the  Prognosis 
depends  very  ranch  upon  the  duration.     Generally,  it  is  unfavorable. 

There  are  no  facts  bearing  on  the  Morbid  Anatomy,  and  the 
Pathology  is  to  be  explained  by  the  principle  of  reflex  excitation 
which,  in  this  case,  probably  takes  place  through  the  intermediation 
of  the  fifth  pair;  by  reference  to  the  facts  ascertained  by  the  experi- 
ments of  Fritsch  and  Ilitzig,  "Nothnagel,  Ferrier,  Bartholow,  and  my- 
self ;  or  by  the  theory  of  irritation  existing  somewhere  in  the  course  of 
the  facial  nerve.  The  latter  is  probably  the  most  common  condition. 
The  analogy  with  chorea  is  very  great. 

Treatment. — Of  fourteen  cases  that  have  been  under  my  charge,  six 
were  cured.  The  means  which  I  have  found  most  useful  are,  daily 
hypodermic  injections  of  a  mixture  in  water  of  five  di'ops  of  Fowler's 
solution,  and  the  one-fiftieth  of  a  grain  of  atropia,  and  the  daily  use  of 
the  galvanic  current  to  the  facial  nerve  and  the  convulsed  muscles. 

In  several  cases  I  have  obtained  good  results  from  permanent  press- 
ure over  the  facial  nerve.  The  gentleman  previously  referred  to  had 
had,  at  my  suggestion,  a  steel  spring  constructed,  which  terminated  in 
two  pads,  and  which  he  wore  over  the  head  in  such  a  way  as  to  com- 
press the  facial  nerves  at  their  exit  from  the  stylo-mastoid  foramen. 
While  he  wore  it  he  had  no  spasms,  but  he  was  unable  to  endure  the 
pressure  longer  than  a  couple  of  hours. 

In  one  case,  that  of  a  young  gentleman,  from  the  interior  of  this 
State,  in  whom  the  disease  had  lasted  about  a  year,  a  permanent  cure 
was  produced  within  a  month  by  the  use  of  the  bromide  of  zinc  in  gradu- 
ally-increasing doses,  as  recommended  for  convulsive  tremor,  and  the 
employment  of  the  primary  galvanic  current  to  the  skin  over  the  facial 
nerve  and  affected  muscles. 

Division  of  the  affected  muscles  has  been  practised  with  very  mod- 
erate success. 

TORTICOLLIS. 

In  this  disease  the  spasms — which,  as  in  the  corresponding  affection 
of  the  face,  may  be  either  clonic  or  tonic — occupy  the  sterno-cleido- 
mastoid,  the  trapezius,  the  rhomboid,  and  the  levator-anguli  scapula?, 
separately  or  collectively.  The  movements  of  the  head  in  the  clonic 
form  depend  upon  the  seat  of  the  spasms,  the  action  being  in  the  direc- 
tion of  the  tractile  force  of  the  affected  muscles.  Sometimes  the  con- 
tractions are  very  rapid,  and  again  they  are  slow  and  regular  ;  as  in 
facial  spasm,  they  are  aggravated  by  emotional  excitement  or  physical 
exertion.  They  cease  during  engrossing  mental  occupation,  and  during 
sleep.     Occasionally  both  sides  are  affected. 

The  reverse  as  regards  facial  spasm,  the  tonic  form,  is  much  the 
more  common,  and  it  is  to  it  that  the  term  torticollis  is  usually  applied 
by  surgical  writers.  The  sterno-cleido-mastoid  is  generally  its  exclu- 
sive seat.     The  contraction  is  often  accompanied  by  pain. 


NEURAL   SPASM.  833 

Causes.— The  etiology  is  not  essentially  different  from  that  of  facial 
spasm. 

Diagnosis.— There  is  no  difficulty  about  the  diagnosis  of  the  clonic 
variety.     The  tonic  form  is,  however,  liable  to  be  confounded  with  u 
similar  affection  so  far  as  appearances  and  oonsequenoes  go,  wind, 
veritable  myositis,  but  which  is  not  an  affection  of   the  nervous  system. 
The  transitory  character  of  the  latter  affection  and  the  sever.-  paini 
sufficient  diagnostic  marks. 

Prognosis. — The  prospect  of  recovery  from  the  clonic  form  ii 
remote.  Of  ten  cases  that  I  have  had  under  my  charge,  fuur  only 
cured. 

Of  the  Morbid  Anatomy,  or  of  the  Pathology,  nothing  is  known, 
though  the  disease  may  be  regarded  as  similar  in  its  pathology  to  facial 
spasm. 

Treatment. — I  have  made  use  of  every  remedy,  in  the  clonic  form, 
which  could  in  my  opinion  be  of  service.  Iron,  belladonna,  arsenic, 
morphia,  chloral,  chloroform,  ether,  bromide  of  potassium,  strvehnia, 
zinc,  and  many  other  medicines,  have  all  failed.  In  on<  oase  1  adminis- 
tered morphia  hypodermically  in  gradually-increasing  doses,  till  at  last 
two  grains  were  given  twice  a  day,  but  without  any  permanent  efi 
I  have  divided  the  muscles  in  four  cases  without  benefit.  In  one  of 
them  I  cut  both  sterno-cleido-mastoids,  the  left  trapezius  at  its  in 
tion  into  the  occipital  bone,  the  left  levator-anguli  scapulae,  and  finallv, 
with  the  concurrence  of  my  friend  Prof.  Markoe,  the  left  oomplexus. 
But  as  soon  as  one  muscle  was  cut  another  became  a£  ad,  after 

the  division  of  the  complcxus,  the  expectation  of  obtaining  a  cure  by 
myotomy  was  given  up.    The  patient,  a  lady,  from  the  South,  remained 
affected  for    several    years,    but  when    I    last    heard    from    her 
had   greatly  improved,  the    disease  hning  apparently  exhausted    its 
power. 

Electricity  in  any  form  has  never  cured  a  case  in  my  hands,  though 
I  have  employed  it  steadily,  for  weeks  at  a  time,  both  as  the  primary 
and  induced  currents.  The  induced  current,  however,  may  be  used  with 
advantage  to  the  musole  of  the  opposite  side  as  a  means  of  improving 
its  nutrition  and  strength. 

In  two  of  the  successful  cases,  many  means  were  tried  wit  hoi;' 
cess.      In  one,  that  of  a  young  man  from  Newark,  in  addition  to  other 
means,  1  divided  the  right  Bterno-cleido-mastoid  musole  twice,  and  it  was 
afterward  out  by  my  friend  Prof.  Sayre.     All  the  operati  ■  un- 

successful, although,  as  in  the  other  oases,  an  apparatus  was  worn 
prevent  the  too  rapid  union  of  tin-  musole.    This  patient  was  finally 
cured  with  lai  of  the  bromide  of  potassium. 

In  another  case,  thai  of  a  lady  of  this  city,  everj  myitis  used  tailed, 
till  I  tried  the  oxide  of  zinc;  she  begun  with  doses  of  two  grains  three 
times  a  day,  which  were  gradually  increased.    When  she  reached  fifteen 


834  DISEASES  OF  THE  PERIPHERAL  NERVOUS  SYSTEM. 

grains  at  a  dose,  the  spasms  ceased  and  did  not  return.  The  bromide 
of  zinc  is  preferable  to  any  other  form  of  the  remedy. 

For  the  tonic  variety,  myotomy  is  the  proper  remedy,  and  it  is  gen- 
erally successful  if  a  suitable  apparatus  be  subsequently  worn. 

Atropia  administered  hypodermically,  as  recommended  by  Da 
Costa,1  has  been  of  great  service  in  two  cases,  but  in  both  it  was  used 
in  conjunction  with  the  bromide  of  zinc  and  faradization  of  the  non- 
spasmic  muscles.  I  began  with  the  one  hundred-and-twentieth  of  a 
grain  at  a  single  daily  injection,  and  gradually  increased  to  the  one 
twenty-fifth.  In  one  case,  a  lady  about  forty  years  of  age,  recovery 
took  place  in  five  weeks;  and  the  other,  a  young  man  twenty  years  of 
age,  in  about  a  month. 

My  experience  leads  me  to  the  conclusion  that  division  of  the 
affected  muscles,  even  if  not  immediately  successful,  is  an  important 
adjunct  in  the  treatment,  and  it  may  with  this  object  be  repeated  sev- 
eral times.  The  effect  is  to  give  predominance  to  the  opposing  muscles, 
indirectly  doing  what  faradization  is  intended  to  accomplish.  This  is 
especially  true  of  the  sterno-mastoid  muscle,  the  usual  seat  of  the  mor- 
bid action. 

In  an  interesting  article,  Dr.  John  W.  Ogle a  discusses  the  question 
of  the  propriety  of  division  of  the  sterno-mastoid  and  spinal  accessory 
nerves.  Thus  far  no  great  success  appears  to  have  followed  the  opera- 
tion. 


CHAPTER  IX. 

NEURAL    ANESTHESIA. 

Almost  any  part  of  the  body  may  be  deprived  of  sensation  from 
causes  acting  on  the  peripheral  nerves.  One  of  the  most  familiar  ex- 
amples of  this  fact  is  the  anaesthesia  produced  in  the  foot  and  leg  by 
pressure  on  the  sciatic  nerve  in  the  act  of  sitting  too  long  in  one  posi- 
tion; another  is  the  loss  of  sensibility  produced  in  the  hand  and  arm  by 
pressure  on  the  ulnar  nerve  as  it  passes  over  the  elbow. 

Anaesthesia  originating  from  cerebral,  spinal,  or  cerebro-spinal  causes, 
has  already  been  considered,  and  the  present  remarks  will  be  strictly 
limited  to  the  anaesthesia  of  peripheral  origin. 

ANAESTHESIA    OP   CUTANEOUS   NERVES. 

Symptoms. — The  symptoms  of  anaesthesia  from  peripheral  causes  do 
not  vary  materially  from  those  which  result  from  central  lesions.    They 

1  "Pennsylvania  Hospital  Reports,"  1868,  p.  392. 

9  "  Clonic  Spasmodic  Contraction  of  the  Muscles  of  the  Neck  possibly  having  its 
Origin  in  some  Affection  of  the  Contents  of  the  Spinal  Canal,"  "  London  Clinical  Society's 
Reports,"  vol.  vi. 


NEURAL   ANESTHESIA.  835 

consist  of  the  various  sensations  of  numbness,  such  as  tingling,  "pins 
and  needles,"  a  feeling  as  if  ants  are  crawling  over  the  skin,  water 
trickling  over  it,  and,  in  complete  cases,  of  absolute  abolition  of  sensi- 
bility. The  conducting  power  of  the  nerve  may  be  impaired  in  so 
much  as  only  to  cause  a  retardation  of  the  velocity  of  excitations,  and 
thus  an  impression  made  on  the  terminal  extremities  of  a  nerve  is  not 
felt  for  a  much  longer  time  than  would  normally  be  the  case.  Periph- 
eral anaesthesia  may  be  accompanied  with  disorders  of  nutrition  from 
irregularity  of  blood-supply.  One  form  of  the  affection,  of  which  I  have 
seen  several  examples,  and  which  probably  owes  its  complication  to 
vaso-motor  spasm,  is  characterized  by  unnatural  whiteness  and  shrink- 
ing of  the  skin,  usually  in  the  hands.  If  an  incision  be  made,  little  or 
no  blood  escapes.  In  a  young  lady  from  Savannah,  who  was  under  my 
charge  a  short  time  since,  this  condition  existed  to  an  extreme  degree, 
but  disappeared  with  the  removal  of  the  anaesthesia.  In  former  times, 
the  test  for  the  identification  of  witches  consisted  in  rinding  a  spot 
which  could  be  pricked  with  a  sharp  instrument  without  the  suspected 
person  feeling  the  wound  and  without  blood  flowing.  As  many  sup- 
posed witches  were  of  highly-nervous  temperaments,  it  is  probable  there 
were  parts  of  their  bodies  into  which  pins  could  be  stuck  without  caus- 
ing pain  or  loss  of  blood,  owing  to  the  existence  of  vaso-motor  spasm 
such  at  that  mentioned.  Anaesthesia  of  peripheral  origin  in  the  cuta- 
neous nerves  is  sometimes  accompanied  by  more  or  less  loss  of  power, 
but  in  such  cases  the  larger  branches  of  the  nerves  must  necessarily  be 
involved. 

In  cutaneous  anaesthesia  there  is  always  a  diminution  of  temperature 
in  the  affected  part,  and  this  is  readily  detected  by  comparison  with 
the  corresponding  healthy  part  by  means  of  Dr.  Lombard's  thermo-elec- 
tric apparatus. 

Sensations  are  sometimes  perverted.  Hot  bodies  applied  to  the  skin 
may  feel  cold,  and  cold  bodies  hot.  Again  there  is  usually  a  loss  of  the 
power  to  discriminate  differences  of  temperature  even  when  they  are 
considerable. 

The  ability  to  distinguish  slight  differences  in  weights  is  usually 
lost,  from  the  fact  that  the  Sense  of  pressure  upon  the  skin  is  dimin- 
ished or  abolished.  If,  however,  the  difference  be  gnat,  the  mu 
will  detect  it  independently  of  the  sense  of  cutaneous  pressure.  The 
sense  of  touch  may  remain,  and  thai  of  pain  be  abolished — or 
versa.  I  have  repeatedly  observed,  in  eases  in  which  1  have  applied 
the  ether-spray  to  the  skin  for  the  purpose  of  preventing  the  pain 
of  the  actual  cautery,  that  the  patient  has  (elf  the  pressure  of  the 
white-hot  instrument,  but  has  been  absolutely  insensible  to  the 
burning. 

The  sesthesiometer  affords  a  ready  means  of  determining  the  com- 
parative and  absolute  loss  of  sensation  in  an  anaesthetic  region,  and  will 


836  DISEASES   OF  THE   PERIPHERAL  NERVOUS  SYSTEM. 

often  be  of  great  service  in  the  formation  of  a  diagnosis  teiween  vari- 
ous subjective  feelings  and  true  insensibility. 

There  are  certain  diseases  of  the  skin  which  are  accompanied  with 
anaesthesia.  The  principal  of  these  are  lepra  anaesthetica,  alopecia 
areata,  pellagra,  acrodynia,  and  Norwegian  lepros}7.  In  such  instances 
the  cutaneous  insensibility  is  probably  not  the  primary  condition,  but  is 
secondary  to  the  special  skin-disorder.1  At  the  same  time  the  symmet- 
rical character  of  some  of  these  affections  is,  by  some  authorities,  re- 
garded as  evidence  of  their  dependence  upon  derangement  of  the  ner- 
vous system. 

Causes. — Peripheral  cutaneous  anaesthesia  may  be  produced  by  a 
variety  of  causes.  Among  the  chief  are  wounds  and  injuries  of  various 
kinds,  whereby  the  nerve  is  divided  or  its  conducting  power  impaired  ; 
pressure  such  as  that  caused  by  tumors,  tight  clothing,  or  accidental 
influences;  rheumatism;  exposure  to  intense  cold,  such  as  that  produced 
by  ice  and  salt  or  the  ether-spray;  the  action  of  certain  drugs,  such  as 
aconite  locally  applied;  frequent  immersion  of  the  hands  in  hot  water 
impregnated  with  soap,  as  in  washer-women ;  or  of  the  body  and  ex- 
tremities in  sea-water,  as  in  the  men  and  women  who  take  bathers  into 
the  ocean;  and  diseases  of  the  nerves. 

Diagnosis. — The  important  point  in  the  diagnosis  of  peripheral  an- 
aesthesia is  the  discrimination  between  it  and  the  anaesthesia,  due  to 
central  causes.  The  elements  of  the  diagnosis  have  been  dwelt  upon 
at  some  length  by  Romberg,  and  perhaps  needlessly  so,  for  there  can 
scarcely  be  a  case  in  which  any  difficulty  in  forming  a  correct  opinion 
can  arise  except  in  those  cases  of  anaesthesia  in  which  the  fifth  pair  is 
involved,  and  they  will  presently  be  more  especially  considered.  As 
regards  the  cutaneous  nerves,  the  existence  of  a  peripheral  cause,  and 
the  non-existence  of  evidences  of  cerebral  or  spinal  derangement,  will 
be  sufficient  indications  of  the  nature  of  the  affection.  It  could  scarcely 
happen  that  anaesthesia,  the  result  of  central  lesions,  could  exist  with- 
out other  marked  symptoms  being  present,  not  connected  with  cases  of 
peripheral  origin. 

Prognosis. — This  depends  very  much  upon  the  cause,  and  the  ability 
to  remove  it.  In  cases  of  simple  division  of  a  nerve,  union  may  be 
effected  after  a  time,  and  the  functions  restored,  but,  if  any  considerable 
portion  of  the  nerve  has  been  destroyed,  the  case  is  hopeless.  Even 
when  the  cause  is  removed,  as  may  be  accomplished  for  instance  in 
cases  due  to  pressure,  a  long  period  often  elapses  before  complete  res- 
toration takes  place. 

1  Fot  a  full  account  of  this  subject  the  reader  is  referred  to  two  papers  on  "  The  Re- 
lations of  the  Nervous  System  to  Diseases  of  the  Skin,"  by  Dr.  L.  D.  Bulkley,  in  the 
Archives  of  Electrology  and  Neurology  for  November,  1874,  and  May,  1875,  and  to  "A 
Memoir  on  Neuroses  of  the  Skin,"  read  before  the  New  York  Neurological  Society,  by 
Dr.  F.  Le  Roy  Satterlee,  and  published  in  the  Psychological  Journal  for  May,  1875. 


NEURAL   ANESTHESIA.  837 

The  Morbid  Anatomy  and  Pathology  call  for  but  few  remarks  after 
what  has  already  been  said.  The  lesion,  whatever  it  may  be,  or  the 
functional  disturbance  if  there  be  no  lesion  discoverable,  is  probably 
situated  in  the  extreme  terminations  of  the  cutaneous  branches  ;  for 
otherwise  we  should  expect  to  find  loss  of  muscular  power  more  fre- 
quently associated  with  the  anaesthesia  than  is  actually  the  case. 

But  M.  Chapoy  '  has  shown  that  there  are  exceptions  to  this  rule, 
and  especially  in  regard  to  the  radial  nerve;  for,  in  cases  of  injury  or 
disease  of  this  nerve  causing  paralysis  of  motion  in  the  muscles  supplied 
by  it,  the  tactile  sensibility  is  in  the  majority  of  instances  preserved. 
This  circumstance  is  explained  by  the  fact  that,  as  MM.  Arloing  and 
Tripier  2  have  shown,  numerous  anastomoses  exist  between  the  radial 
and  ulnar  nerves. 

Treatment. — The  most  important  therapeutic  measure  consists  in 
the  removal  of  the  cause.  Unless  this  can  be  effected,  it  is  useless  to 
attempt  other  treatment.  If  this  can  be  accomplished,  electricitv  iz 
the  most  efficient  agent  to  be  employed  toward  restoring  the  irritability 
to  the  nerves.  Sometimes  the  primary  current  is  to  be  preferred,  at 
others  the  induced.  In  the  latter  case  the  wire  brush  should  be  used 
as  one  of  the  electrodes,  and  the  anaesthetic  parts  be  stroked  with  it  at 
each  seance. 

ANAESTHESIA    OF   THE    FIFTH   PAIR. 

Symptoms. — These  vary  according  to  the  seat  of  the  lesion.  If  the 
ophthalmic  branch  alone  be  implicated,  the  anresthesia  is  situated  in 
the  forehead,  the  upper  eyelid,  the  conjunctiva,  and  the  lining  mem- 
brane of  the  nostril.  Irritating  substances,  therefore,  coming  in  con- 
tact with  the  eye  or  the  pituitary  membrane,  are  not  felt,  though  as 
regards  the  latter  the  sense  of  smell  remains. 

If  the  trouble  is  limited  to  the  superior  maxillary  branch,  the  skin 
of  the  upper  part  of  the  face  and  the  teeth  of  the  upper  jaw  are  in- 
sensible. When  the  inferior  maxillary  branch  is  affected,  the  temporal 
region,  the  skin  covering  the  upper  and  lower  jaw,  the  under  lip,  the 
chin,  the  lining  membrane  of  the  mouth,  the  anterior  third  of  the 
tongue,  and  the  teeth  of  the  lower  jaw,  lose  their  sensibility  ;  mastica- 
tion becomes  difficult,  and  the  saliva  flows  from  the  mouth.  In  either 
of  these  cases  the  scat  of  the  lesion  must  be  anterior  to  the  Gasserian 
ganglion.  When  all  the  branches  of  the  fifth  are  involved,  and,  as  a 
consequence,  anaesthesia  exists  throughout  the  whole  of  one  side  of  the 
face,  it  is  very  certain  that  the  ganglion  is  affected,  or  that  the  main 
trunk  of  the  nerve  is  itself  the  seat  of  the  disease.  Anesthesia  of  the 
iii'th  nerve  due  to  lesion  of  the  Gasserian  ganglion,  or  of  the  main 

1  'Tk'  la  paralysis  du  aerf  radial,"  These  de  Paris,  1874. 

*  "Recberches  sur  la  sensibility  dea  teguments  et  dcs  nerfs  de  la  main,"  Arckhm 
dc  physiotoyic,  1869,  p.  33. 


838  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

trunk,  is  very  generally  accompanied  by  disorders  of  nutrition  and  de- 
rangement of  the  senses  of  sight,  smell,  and  taste.  Fungoid  growths 
on  the  gums  and  defective  circulation  in  the  face  are  common  in  such 
cases  ;  but  ulceration  of  the  cornea  and  congestion  of  the  conjunctiva 
do  not  occur  unless  the  lesion  is  situated  in  the  Gasserian  ganglion,  or 
anterior  to  it  in  the  ophthalmic  branch. 

The  Causes  of  peripheral  anaesthesia  of  the  fifth  pair  are  analogous 
to  those  which  produce  the  corresponding  affection  in  the  cutaneous 
nerves,  cold  being  the  chief  among  them.  Rendu,1  in  his  very  complete 
monograph,  expresses  the  opinion  that  the  majority  of  the  cases  of 
anaesthesia  of  the  fifth  pair  are  due  to  neuritis. 

The  Diagnosis  requires  a  few  special  remarks,  and  these  may  be 
stated  in  the  form  of  Romberg's  propositions  : 

"  a.  The  more  the  anaesthesia  is  con6ned  to  single  filaments  of  the 
trigeminus,  the  more  peripheral  the  seat  of  -the  cause  will  be  found  to 
be. 

"  b.  If  the  loss  of  sensation  affects  a  portion  of  the  facial  surface, 
together  with  the  corresponding  facial  cavity,  the  disease  may  be  as- 
sumed to  involve  the  sensory  fibres  of  the  fifth  pair  before  they  separate 
to  be  distributed  to  then  respective  destinations  ;  in  other  w7ords,  a 
main  division  must  be  affected  before  or  after  its  passage  through  the 
cranium. 

"  c.  When  the  entire  sensory  tract  of  the  fifth  nerve  has  lost  its 
power,  and  there  are  at  the  same  time  derangements  of  the  nutritive 
functions  in  the  affected  parts,  the  Gasserian  ganglion,  or  the  nerve  in 
its  immediate  vicinity,  is  the  seat  of  the  disease. 

"  d.  If  the  anaesthesia  of  the  fifth  nerve  is  complicated  with  dis- 
turbed functions  of  adjoining  cerebral  nerves,  it  may  be  assumed  that 
the  cause  is  seated  at  the  base  of  the  brain." 

The  Prognosis,  the  Morbid  Anatomy,  the  Pathology,  and  the  Treat- 
ment, require  no  remarks  additional  to  those  made  when  peripheral  cu- 
taneous anaesthesia  was  under  consideration,  except  that,  as  regards 
the  treatment,  if  the  primary  current  is  employed,  care  should  be  taken 
that  the  tension  be  not  too  high,  a  point  to  which  reference  has  already 
frequently  been  made. 


CHAPTER  X. 

NEURAL  HYPERESTHESIA  (NEURALGIA). 

Under  this  head  I  propose  to  consider  the  principal  painful  affec- 
tions embraced  under  the  term  neuralgia.     No  designation  in  medical 
Gomenclature  has  been  more  abused  than  this.     Any  pains,  the  origin 
1  "  Des  anesthesies  spontanees,"  Paris,  1875,  p.  107. 


NEURAL   HYPERESTHESIA.  939 

of  which  cannot   readily  be  ascertained,  and  many  which  are  well 
known  to  depend  upon  central  lesions,  are  called  neuralgic.     I  pro- 
pose, in    the    present    remark-,  to    include    under   it   those  affed 
only  which,  so   far   as   can    be   ascertained,  are   not    due  to  die 
either  of  the  brain  or  spinal  cord,  but   th<  :    which   i>  in  the 

nerves  themselves.      Following  the  classification  of  Valleix,  I  shall 
consider — 

a.  Neuralgia  of  the  fifth  pair. 

b.  Cervico-occipital  neuralgia. 

c.  Cervico-brachial  neuralgia. 

d.  Dorso-intereostal  neuralgia. 

e.  Lumbo-abdominal  neuralgia. 

f.  Crural  neuralgia. 

NEURALGIA   OP   THE    FIFTH   PAIR    OF   NBSVBS. 

Symptoms. — Either  division  of  the  fifth  pair  of  nerves  may  be  the 
seat  of  the  disease,  or  all  may  be  simultaneously  affected. 

1.  Ophthalmic  Division. — This  branch  of  the  fifth  is  distributed  to 
the  side  of  the  nose,  the  eyelids,  the  lachrymal  gland,  the  globe  of  the 
eye,  the  conjunctiva,  the  forehead,  and  the  scalp.  The  long  root  of  the 
ciliary  ganglion  communicates  with  the  nerve,  and  anastomoses  take 
place  with  the  superior  maxillary  branch. 

Valleix  has  shown  that  there  are  particular  spots  in  which  neuralgic 
pains  are  always  more  severe  than  in  others,  and  that  these  are  the 
points  where  the  nerve  either  passes  through  a  foramen  in  a  bone,  or 
penetrates  a  fascia.  In  the  ophthalmic  nerve  several  of  these  points 
are  to  be  found.  The  most  prominent  is  in  the  nerve  as  it  passes  out 
of  the  supra-orbital  foramen  to  ramify  on  the  forehead  and  scalp  ;  an- 
other is  seated  in  the  upper  eyelid  ;  another  in  the  long  nasal  branoh 
as  it  passes  to  the  skin  through  the  line  of  union  of  the  nasal  bone  with 
the  cartilage;  another  is  located  in  the  eyeball,  and  another  at  the 
inner  angle  of  the  orbit.  Besides  these  which  are  peculiar  to  the  oph- 
thalmic branch,  there  is  another  situated  near  the  parietal  eminence,  and 
which  corresponds  to  the  inosculation  of  various  branches. 

The  most  common  form  of  neuralgia  affecting  the  ophthalmic  divis- 
ion of  the  fifth  nerve  is  hemiorania.     The  occurrence  of  the  paroxj 
is  marked  by  a  tendency  to  periodicity.     The  pain  is  exceedingly  sharp 
and  lancinating,  and  occupies  the  frontal,  temporal,  or  parieta 
being  especially  intense  at  the  point  corresponding  to  the  supra-orbital 
foramen,  or  at  least  thai  situated  near  the  parietal  eminence,     li 
quently  happens  that  this  latter  spot    is  the  only  pari  affected.     The 
paroxysm  usually  comes  on  in  the  morning,  and  rarely  [asl  than 

twenty-four  hours;  frequently  it  disappears  at  nightfall.    The  pain  is 
greatly  aggravated  by  mental  or  physical  exertion,  by  1 
bright  lights.    It  is  often  complicated  with  nausea  and  vomiting,  in 


840  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

which  case  it  constitutes  what  is  known  as  sick -headache.  In  other 
cases  the  pain  is  mainly  confined  to  the  eyeball  and  the  accessory  parts. 
There  is  then  lachrymation,  from  the  fact  that  the  lachrymal  gland  is 
supplied  from  the  ophthalmic  division,  and  there  may  be  visual  troubles 
from  the  relation  which  the  nerve  bears  to  the  ciliary  ganglion. 

This  form  may  also  be  distinctly  periodical  in  its  occurrence,  and  it 
rarely  lasts  longer  at  one  time  than  twenty-four  hours. 

2.  Superior  Maxillary  Division. — The  distribution  of  this  branch 
is  to  the  teeth  of  the  upper  jaw,  the  lower  eyelid,  the  side  of  the  nose, 
the  upper  lip,  to  the  lining  membrane  of  the  nose  and  mouth,  and  to 
the  temple  and  cheek.  It  inosculates  freely  with  the  ophthalmic  divis- 
ion, and  is  in  intimate  relations  with  the  spheno-palatine  ganglion. 

The  painful  points  of  Valleix  for  this  nerve  are,  in  the  infra-orbital 
nerve  as  it  emerges  from  the  infra-orbital  foramen  to  be  distributed  to 
the  lower  eyelid,  the  side  of  the  nose,  and  the  upper  lip;  over  the  most 
prominent  part  of  the  malar  bone,  where  the  nerve  is  very  superficial ; 
an  uncertain  point  on  the  gums  of  the  upper  jaw  ;  a  similar  point  on 
the  upper  lip,  and  another  on  the  palate.  Neuralgia  of  this  division 
occurs  in  paroxysms,  and  may,  like  that  of  the  ophthalmic,  be  periodi- 
cal in  its  attacks. 

3.  Inferior  Maxillary  Division. — This  nerve  is  distributed  to  the 
cheek,  the  tongue,  the  lower  jaw  and  teeth,  and  to  the  sub-maxillary 
gland.  It  is  also  in  connection  with  the  otic  and  sub-maxillary  gan- 
glia. 

Its  painful  points  are  a  spot  on  the  auriculo-temporal  branch,  just 
in  front  of  the  ear  ;  another  on  the  inferior  dental  nerve,  where  it 
emerges  from  the  inferior  dental  canal,  through  the  mental  fora- 
men. 

It  is  generally  the  case  that  facial  neuralgia  is  limited  to  one  side, 
but  both  are  sometimes  affected.  It  may  also  be  confined  to  very 
restricted  boundaries,  the  extreme  terminal  branches  alone  being  in- 
volved. 

Causes. — According  to  my  experience,  facial  neuralgia  is  rarely  met 
with  in  young  persons,  but  is  more  common  during  adult  life.  It  is 
certainly  more  apt  to  attack  females  than  males,  and  is  often  transmit- 
ted by  hereditary  influence. 

The  most  common  exciting  cause  is,  in  this  country,  malaria,  and 
this  is  especially  the  case  with  the  affection  in  the  ophthalmic  division, 
as  manifested  in  hemicrania  and  supra-orbital  neuralgia.  This  latter  is 
often  popularly  known  as  "  brow-ague." 

Among:  other  causes  are  to  be  mentioned  mental  excitement,  anxi- 
ety,  intense  intellectual  exertion,  exposure  to  cold  and  damp,  the  loss 
of  blood,  as  in  the  case  of  women  after  childbirth,  or  from  menor- 
rhagia,  prolonged  lactation,  and  the  changes  due  to  the  cessation  of  the 


NEURAL   HYPERESTHESIA.  Ml 

Another  very  common  cause  is  syphilis,  and  there  is  reason  to  think 
that  the  gouty  diathesis  may  also  excite  it. 

But,  as  Anstie  '  remarks,  it  is  after  the  powers  of  life  begin  to  de- 
cline that  the  most  formidable  varieties  of  facial  neuralgia  are  encoun- 
tered.    Those  forms  which  are  attended  with  muscular  spasm,  consti- 
tuting the  "tic  douloureux"  of  the  French,  and  another  still   more 
violent  which  Trousseau  has  designated  "tic  epileptiform, "  are  aim 
peculiar  to  advanced  life.    The  pain  in  these  affections  is  atroci 
is  excited  by  the  least  muscular  action  in  the  face,  by  a  touch,  In  m 
light,  or  even  by  a  breath  of  air.     They  are  often  accompanied  1  v  a 
hereditary  tendency  to  insanity,  and  they  eventually  \  the  life 

of  the  miserable  sufferer. 

Facial    neuralgia   may   also    result    from    tumors    coi:  g    the 

nerves,  from  thickening  of  the  bones,  or  of  the  periosteum,  causing 
narrowing  of  the  foramina  through  which  they  pass,  ami  from  intersti- 
tial organic  changes  taking  place  in  the  ncrve-tru: 

The  Diagnosis  requires  no  special  remarks,  ami  the  Prognosis  de- 
pends upon  the  cause,  and  the  ability  to  remove  it.  In  g 
it  may  be  stated  that  the  malarial  and  syphilitic  firms  are  usually  read- 
ily cured,  while  others  are  seldom  thoroughly  relieved.  The  intense 
varieties,  coming  on  for  the  first  time  late  in  life,  are  absolutely  incu- 
rable, and  are  very  seldom  oapable  of  even  being  mitigated. 

rKKVICO-OCCIPITAL    MCI  i:\LGIA. 

In  this  affection  the  pain  is  situated  in  the  sensory  branches  of  the 
first  four  cervical  nerves,  though  the  great  occipital  which  arises  from 
the  second  cervical  is  mainly  the  one  affected.  These  nerves  are  dis- 
tributed to  the  occipital  and  posterior  parietal  regions,  as  will  as  to  tin- 
neck  and  lower  part  of  the  cheek.  The  painful  points  are  those  at 
which  the  nerves  become  most  superficial. 

The  pain  in  cervico-oecijit.d  neuralgia,  though  severe,  is  not  in  gen- 
eral so  intense  as  that  of  the  facial  variety.  There  is  a  tendency  in 
the  alTection  to  extend  so  as  to  involve  the  inferior  maxillary  nerve, 
and,  when  the  disease  has  lasted  some  time,  a  paroxysm  rarely  ooonra 
without  this  nerve  being  implicated.  Alt  er  the  acute  stage  of  a  par- 
oxysm has  passed  off,  there  remains  a  dull,  heavy  pain,  which  oontinnea 

.  and  which  is  increased  by  the  pressure  of  the  olothing 
mental  exertion,  or  by  moving  the  head. 

The  C&U888  are  similar  in  general  oharaoter  to  those  of  facial  neu- 
ralgia, though  c.,1.1  is  probably  a  still  mure  powerful  factor  in  the  eti- 
Dlogy. 

The  Diagnosis  ami  Prognosis  oall  for  no  special  remarks, 

1  Articlt!  "  Neuralgia,    in  Reynolds's  "System  of  Medicine,'1  vol.  ii.,  p  ; 


842  DISEASES   OF  THE   PERIPHERAL   NERVOUS   SYSTEM. 


CERVICO-BRACHIAL   NEURALGIA. 

In  this  form  the  brachial  plexus,  the  nerves  which  go  to  form  it — 
the  five  lower  cervical  and  first  dorsal — and  those  which  arise  from  it, 
are  the  seat  of  the  affection.  The  pain  may  therefore  be  felt  in  the 
subclavicular  region,  along  the  whole  length  of  the  upper  extremity,  or 
in  the  situation  of  the  mammary  gland.  The  exact  seat  varies  of  course 
with  the  particular  nerve  affected.  It  is  often  accompanied  by  various 
sensations  of  numbness,  and  interferes  more  or  less  with  the  movements 
of  the  limb.  The  principal  painful  points  are  the  axillary  in  the  arm- 
pit, and  corresponding  to  the  brachial  plexus,  the  scapular  near  the  in- 
ferior angle  of  the  scapula,  the  acromial  in  the  angle  between  this  pro- 
cess and  the  clavicle,  the  median  cephalic  in  the  bend  of  the  elbow,  the 
ulnar  corresponding  to  the  most  superficial  portion  of  the  ulnar  nerve 
at  the  back  of  the  elbow-joint,  and  the  radial  at  the  point  where  the 
radial  nerve  becomes  superficial  at  the  lower  part  of  the  forearm. 

Among  the  Causes  of  cervico-brachial  neuralgia,  rheumatism,  mala- 
ria, excessive  muscular  exertion,  and  injuries,  are  preeminent.  It  is  not 
so  frequently  the  result  of  malaria  as  the  corresponding  affection  of  the 
facial  nerve. 

There  is  nothing  special  to  be  said  relative  to  the  Diagnosis  and 
Prognosis. 

DORSO-INTERCOSTAL   NEURALGIA. 

In  this  affection  the  dorsal  and  intercostal  nerves  are  the  seat  of  the 
pain.  In  the  first  case  the  disease  is  often  regarded  as  rheumatic  or 
muscular,  and  has  received  the  popular  name  of  lumbago  ;  in  the  latter 
it  is  often  known  as  pleurodynia.  Whether  in  the  dorsal  or  intercostal 
form,  the  pain  does  not  often  occur  in  well-marked  paroxysms,  but  is 
more  or  less  continuous  in  character,  and  is  much  increased  by  muscu- 
lar exertion.  In  the  dorsal  form,  the  mere  act  of  straightening  the 
back  causes  great  suffering,  and,  in  the  intercostal,  respiration  is  ex- 
ceedingly painful. 

The  painful  points  are  very  numerous,  and  in  general  correspond  to 
the  situations  where  the  nerves  become  most  superficial. 

The  association  of  intercostal  neuralgia  with  herpes  zoster  of  uni- 
lateral form  is  an  interesting  fact,  and  one  which  led  to  the  recognition 
of  other  skin-diseases  as  being  essentially  nervous  affections. 

The  Causes  of  dorso-intercostal  neuralgia  are  cold,  rheumatism, 
malaria,  exhaustion,  and,  in  women,  the  depression  of  vital  power,  due 
to  profuse  menstruation  or  prolonged  lactation.  Anasmia,  both  in 
males  and  females,  is  also  a  common  cause,  however  produced. 

The  Diagnosis  of  the  dorsal  form  is  not  a  matter  of  difficulty  ;  the 
intercostal  has,  however,  often  been  mistaken  for  pleurisy.  The  Prog- 
nosis is  more  favorable  than  in  the  other  neuralgias  described. 


NEURAL    HYPERESTHESIA.  843 

Lumbo-abdominal  and  crural  neuralgia*  are  not  very  common. 
The  latter  is  seldom  a  primary  affection. 

Morbid  Anatomy  and  Pathology. — The  remarks  which  might  be 
made  under  this  head  have  already  been  expressed  to  some  extent  in 
the  foregoing  pages,  and  there  is  not  much  more  that  could  be  said 
without  entering  the  domain  of  pure  speculation.  I  may,  however, 
state  my  opinion  that  neuralgia,  not  directly  the  result  of  some  physi- 
cal cause  interfering  with  the  integrity  of  the  nerve  in  which  it  is  situ- 
ated, is  almost  invariably  induced  by  a  depressed  state  of  the  system. 
Its  existence  in  such  cases  is  evidence,  therefore,  of  deficient  physical 
stamina,  and  of  the  fact  that  the  nervous  system  is  not  duly  nourished. 
The  remote  factor  may  be  malaria,  syphilis,  rheumatism,  gout,  or  some 
other  cause  capable  of  lowering  the  vitality  of  the  organism,  and, 
as  a  consequence,  that  of  the  nerves.  It  is  of  course  of  the  utmost 
importance  with  reference  to  the  treatment,  to  ascertain  whether 
there  is,  or  is  not,  any  such  constitutional  taint,  but,  whatever  the 
result  of  our  inquiries  in  this  direction,  that  system  of  therapeutics 
is  best  which,  in  addition  to  special  medication,  embraces  restorative 
means. 

Treatment. — The  measures  which  it  is  proper  to  employ  in  neu- 
ralgia may  be  divided  into  two  categories,  the  constitutional  and  the 
local. 

Among  the  constitutional  remedies  must  be  included  those  which 
are  for  the  correction  of  any  taint  which  may  be  present.  If  there  is 
reason  to  suspect  the  existence  of  syphilis,  iodide  of  potassium  is  an 
indispensable  remedy,  and  should  be  given  in  large  doses.  It  is  also 
advisable  in  rheumatic;  neuralgias,  especially  of  the  ccrvico-occipital 
region.  If  malaria  can  be  ascertained  to  have  exerted  an  influence, 
quimne  must  be  administered;  and,  indeed,  it  Lb  safe  to  act  upon  the 
theory  that  this  has  been  the  cause,  unless  some  other  can  be  clearly 
made  out.  It  must  be  recollected  that  malaria  may  give  rise  to  neu* 
ralgia,  especially  in  the  facial  nerve,  without  there  having  been  any 
other  manifestation  of  its  toxio  effect  ;  and  that  the  affection  is  i 
cured  by  large  doses  of  quinine,  when  the  patient  has  nol  apparently 
been  subjected  to  the  malarious  influence.     Should  there  be  do  relief 

r  three  or  four  ten-grain  doses  of  quinine,  it  should  still  not  be  de- 
I  that  the  disease  is  not  of  malarious  origin,  but  the  quinine  should 
lie  given  ui  still  larger  doses,  as  in  Dr.  Clinton  Wagner's  own  case,  in 
which  fifty  grains  were  taken  in  eight  or  ten  hours.'  [f  there  i-  Mill  n<> 
improvement,  arsenic  should  be  administered,  I  have  Been  many  i 
of  supraorbital  neuralgia,  undoubtedly  the  result  <<(  miasmatic  poison' 
ing,  effectually  cured  by  arsenic,  when  quinine  hail  failed.  Prom  my 
own  experience,  I  am  very  wrell  oonvinoed  that  it  acts  much  moreeffica- 

1  "  Proceedings  of  the  New  Vm-lc  Neurological  Society,"  Ptytkoto, 
1874,  p.  126. 


844  DISEASES  OF  THE  PERIPHERAL  NERVOUS  SYSTEM. 

ciousl y  when  administered  by  hypodermic  injection  than  by  the  stomach. 
Four  drops  of  Fowler's  solution,  diluted  with  an  equal  quantity  of 
water,  should  be  given  twice  a  day,  and  the  quantity  should  be  gradu- 
ally increased  to  eight  or  ten  drops  at  a  dose.  Even  in  cases  not 
malarious,  arsenic  will  often  be  found  to  be  a  most  valuable  therapeutic 
agent. 

If  a  gouty  diathesis  is  present,  colchicum  should  be  used  ;  and,  if 
rheumatism  be  clearly  made  out,  the  blood  should  at  once  be  rendered 
alkaline  by  liquor  potassae. 

Whether  any  specific  trouble  be  discovered  or  not,  general  ton- 
ics are  always  indicated ;  among  them  coddiver  oil  occupies  the 
front  rank,  and  iron  is  "not  far  behind  it  in  value  ;  strychnia  is 
also  very  generally  useful.  Among  constitutional  remedies,  ergot 
has  proved  of  very  decided  benefit  in  my  hands.  It  should  be 
given  in  large  doses,  a  drachm  or  more  of  the  fluid  extract  three  times 
a  day. 

A  full  and  nutritious  diet  is  of  great  value  in  the  treatment  of 
neuralgia,  as  are  likewise  sunlight,  and  pure  and  fresh  air. 

In  addition  to  these  purely  constitutional  measures,  there  are 
others  which,  though  administered  to  act  upon  the  system  at  large, 
are  given  for  the  purpose  of  arresting  a  paroxysm,  or  deadening  sensi- 
bility, so  as  to  prevent  the  pain  being  felt.  The  medicines  embraced 
in  this  category  are  included  among  the  stimulants,  narcotics,  and 
anaesthetics. 

Opium  and  its  various  preparations  are  preeminent  as  palliatives  of 
the  neuralgic  paroxysm,  and  morphia  stands  first  among  them.  It  is 
most  efficaciously  administered  hypodermically,  in  doses  varying  from 
one-sixth  grain  to  half  a  grain,  or  even  more  in  extreme  cases.  Great 
care  should  be  exercised  in  its  use,  and  the  smaller  quantity  mentioned 
should  not  be  exceeded  except  by  regular  gradations.  It  is  immaterial 
in  what  part  of  the  body  the  injection  is  made,  so  far  as  its  influence 
over  the  pain  is  concerned. 

Among  other  medicines  of  this  class  are  belladonna,  or  its  alkaloid 
atropia,  Indian  hemp,  aconite,  gelseminum,  bromide  of  potassium,  hy- 
drate of  chloral,  hyoscyamus,  conium,  and  some  others  of  minor  impor- 
tance. 

Of  these,  aconite  is  preferably  employed  in  the  form  of  Duquesnel's 
aconitia,  and  is  often  remarkably  efficacious  when  all  other  means  have 
failed.  It  should  be  used  with  great  caution,  and  the  doses  be  very 
gradually  increased,  till  some  decided  evidence — numbness  in  the  arms 
and  legs,  for  instance — of  its  physiological  action  or  the  cessation  of 
the  pain  be  obtained.  I  usually  give  it  in  solution  in  dilute  alcohol  in 
the  proportion  of  one  grain  to  the  ounce.  Four  minims  of  this,  equal 
to  the  T|¥  of  a  grain,  are  enough  to  begin  with.  In  two  hours  a  dose 
of  five  minims  may  be  given,  and  so  on,  if  necessary,  up  to  ten  minims, 


NEURAL   HYPERESTHESIA.  845 

or  ^  of  a  grain.  Beyond  this  I  have  never  ventured,  and  only  once 
have  I  carried  the  dose  to  this  point.  The  patient,  a  master  brass-fin- 
isher, had  suffered  with  intense  left  facial  neuralgia,  which  had  resisted 
every  means  that  had  been  tried.  When  be  first  consulted  me,  I  found 
some  reason  to  suspect  the  existence  of  a  syphilitic  taint,  and  I  treated 
him  with  large  doses  of  iodide  of  potassium.  This  was  in  the  early 
part  of  August,  1880.  He  gradually  improved,  and,  while  taking  one 
hundred  and  eighty  grains  a  day,  declared  himself  free  from  all  pain. 
I  continued  the  remedy  for  a  couple  of  weeks  longer,  and  then  stopped 
its  administration.  But  in  a  month's  time  he  returned,  with  the  pain 
as  bad  as  ever.  I  again  tried  the  iodide,  with  mercury  in  addition,  but 
without  the  least  effect,  so  far  as  mitigating  his  suffering  was  con- 
cerned. I  then  gave  Duquesners  aconitia  in  the  way  mentioned.  At 
eight  drops  he  began  to  experience  relief,  though  there  was  a  general 
burning  sensation  over  the  whole  body,  and  great  physical  and  mental 
prostration.  I  gave  nine  drops,  and  two  hours  afterward  ten,  with 
the  effect  of  entirely  stopping  the  pain  ;  and  up  to  this  time,  four 
months  having  elapsed,  there  has  been  no  relapse.  Sometimes  it  fails. 
It  did  so  notably  in  one  of  the  worst  cases  of  spasmodic  facial  neural- 
gia I  ever  saw,  anil  which  I  brought  before  the  American  Neurological 
Association  at  its  meeting  in  June,  1880  ;  but  I  have  had  several  cases 
of  a  very  severe  type  in  which  its  effect  was  all  that  could  be  desired, 
and  others  in  which  it  produced  marked  alleviation.  Dr.  R.  F.  Weir' 
ha-  reported  an  interesting  case  of  cure  by  its  use.  It  is  especially 
useful  in  facial  neuralgia.  Gelseminum  is  also  a  drug  of  undoubted 
power  over  neuralgia.  Dowse'  expresses  the  opinion  that  its  action  is 
more  specifically  exercised  upon  the  dental  branches  <>f  the  inferior 
maxillary  nerve,  and  I  am  inclined  to  concur  with  him  in  this  view. 

Of  very  great  value  are  chloroform  and  ether,  administered  by 
inhalation,  and  the  various  forms  of  alcoholic  liquors.  It  not  unfre- 
quently  happens  that  an  attack  of  neuralgia  can  be  at  once  aborted  by 

an   ounce   or  two   of    whiskey  or   brandy,   especially   in    a    person    not 

habituated  to  their  use. 

A  somewhat  different  class  of  remedies  for  neuralgia  are  tho86 
which  are  either  tonic  to  the  nervous  or  general  system,  without,  as 
quinine  ami  arsenic,  being  antagonistic  to  malaria.  Among  these  are 
strychnia,  phosphorus,  and  iron. 

Of  these,  strychnia  is,  I  think,  most  efficacious  when   administered 

hypodermically  in  doses  of  from  the  one  forty-eighth  grain  to  the  one 

thirty-Second    grain    twice    daily;     or    it    may    be    given    internally    in 

somewhal  larg<  r  doses  three  times  a  day. 

1  have  long  used  phosphorus  in  the  treatment  of  neuralgia.     I  at 

'  Arehivet  of  Medicine,  August,  1879. 

•"Neuralgia;   it-  Nature  and  Curative  Treatment,"  London  and  Hen  York,  I 

p.  33. 


846  DISEASES  OF  THE  PERIPHERAL  NERVOUS  SYSTEM. 

one  time  extensively  employed  the  phosphoretted  oil,  but  more  recently 
have  substituted  the  phosphide  of  zinc,  which,  I  think,  is  altogether  a 
preferable  form  of  administration.  The  formula  given  on  page  68 
will  fulfill  every  indication  for  phosphorus  and  strychnia.  These  two 
remedies  are  particularly  beneficial  in  neuralgia  occurring  in  persons 
who  have  exhausted  the  vital  powers  by  dissipation  and  excesses  of 
various  kinds. 

Iron  is  especially  valuable  in  cases  of  neuralgia  due  to,  or  accom- 
panied with,  an  ana?mic  condition  of  the  system.  Anstie  speaks  highly 
of  the  tincture  of  the  chloride,  and  ascribes  to  it  a  marked  and  direct 
influence  upon  the  nervous  centres  different  from  that  produced  by 
other  preparations  of  the  mineral.  It  should  be  given  in  doses  of 
thirty  or  forty  minims,  properly  diluted  in  water,  three  times  a  day. 
"While  recognizing  the  benefit  to  be  derived  from  this  agent,  I  have 
generally  preferred  the  sesquioxide  in  powder,  which  can  be  taken 
without  injury  to  the  teeth  or  probability  of  stomach  derangement. 
Large  doses — twenty  to  forty  grains  three  times  a  day — should  be 
employed. 

The  chief  local  means  of  treatment  consist  of  counter-irritation  and 
the  application  of  certain  substances  calculated  to  deaden  the  sensi- 
bility of  the  nerves.  Under  the  former  head  come  blisters  and  the 
various  stimulating  or  irritating  liniments,  essential  oils,  solutions,  and 
the  actual  cautery.  Blisters  should  be  applied  along  the  course  of  the 
affected  nerve.  They  are  especially  valuable  in  sciatica.  Liniments 
are  rarely  of  much  service,  and,  moreover,  they  are  dirty.  Of  the 
essential  oils,  that  of  a  species  of  peppermint  put  up  by  the  Japanese  is 
sometimes  of  immediate  service  in  supra-orbital  neuralgia,  as  is  also 
strong  aqua  ammonias.  The  actual  cautery  often  affords  prompt  relief, 
either  when  applied  over  the  nerve  or  to  some  distant  part  of  the  body. 
In  sciatica,  P>b  l  speaks  of  the  palliative  effect  of  the  red-hot  iron 
applied  to  the  external  ear.  As  he  very  properly  remarks,  the  fact 
that  we  cannot  explain  the  ratio; Kile  of  its  action  is  no  reason  why  we 
should  ridicule  its  use. 

Of  sedative  applications,  the  tincture  of  aconite,  belladonna,  opium, 
etc.,  are  sometimes  of  service.  Dr.  DoAvse,  in  the  excellent  little  work 
already  cited,  speaks  highly  of  a  solution  of  chloral  hydrate  applied 
externally  as  being  efficacious  even  when  the  same  drug  given  inter- 
nally has  failed  to  give  relief.  His  method  of  using  it  is  to  make  a 
solution  in  the  proportion  of  one  ounce  of  chloral  to  sixteen  of  water. 
This  is  then  made  hot.  Three  layers  of  lint  dipped  in  this  solution 
are  next  applied  to  the  skin  over  the  affected  part,  and  over  these  three 
or  four  folds  of  flannel,  previously  soaked  in  very  hot  water  and  wrung 
as  dry  as  possible.  Over  the  Avholc  a  piece  of  India  rubber  sheeting 
is  placed.     The  whole  is  then  bound  firmly  to  the  surface,  and  left  in 

1  Ziemssen's  "Handbuch,"  Band  xii.,  p.  162. 


NEURAL   HYPERESTHESIA.  847 

position  for  six  or  eight  hours.  When  removed,  the  skin  should  he 
painted  with  collodion  or  dusted  with  starch,  and  then  covered  with 
cotton  wool. 

I  have  tried  this  process  in  one  very  severe  case  of  crural  neuralgia, 
and  in  one  of  cervico-occipital  neuralgia,  both  of  which  were  obstinate 
.  with  very  gratifying  success. 

Heat,  either  dry  or  moist,  is  of  itself  of  service  in  most  cases,  and 
cold,  in  the  form  of  ice,  sometimes  relieves  neuralgic  pain  very 
promptly. 

But,  above  all  local  means,  not  only  for  relieving  the  pain  of  any 
particular  paroxysm,  but  also  for  effecting  a  permanent  cure,  electricity 
stand-  first.  I  have  employed  it  in  every  possible  form,  and  am  satis- 
fied that  the  primary  galvanic  current  is  the  preferable  agent.  Indeed, 
I  very  much  doubt  if  the  faradaic  current,  unless  in  a  few  cases,  when 
the  wire-brush  has  been  employed,  has  ever,  in  my  experience,  accom- 
plished any  very  decided  benefit.  In  the  employment  of  the  galvanic 
current,  the  positive  pole  should  be  applied  over  the  seat  of  the  pain. 
The  current  should  be  feeble  at  first,  but  should  be  gradually  increase!, 
without  interrupting  it,  up  to  the  point  of  toleration.  The  application 
should  he  continuous  for  at  least  half  an  hour,  and  should  be  repeated 
every  day  for  several  weeks,  and  in  extreme  cases  longer.  I  have 
cured  a  number  of  severe  cases  of  nearly  every  kind  of  neuralgia  by 
the  aid  of  electricity  when  other  means  had  entirely  failed.  I  rarely, 
however,  employ  it  without  at  the  same  time  insisting  on  such  consti- 
tutional treatment  as  the  case  seems  to  require. 

As  to  surgical  operations  on  the  affected  nerves,  either  of  section  or 
excision  of  a  portion  of  their  continuity,  the  success  which  has  hitherto 
followed  them  has  not  been  such  as,  in  my  opinion,  to  warrant  their 
repetition. 

Hut  there  are  two  other  surgical  means  of  treatment  in  certain  neu- 
ralgic affections  which  have  been  recently  introduced,  and  which  are 
entitled  to  something  more  than  a  mere  passing  reference.  These  are 
"  nerve-stretching"  and  "nerve-compression." 

The  former  has  been  practised  mainly  on  the  sciatic  nerve,  for  the 
relief  of  sciatica— though  il  is  applicable  to  other  nerves,  i  have  oper- 
ated on    the  sciatic  nerve   in  this  way  live  times,  and  with  the  result  of 

affording  immediate  ami,  up  to  the  presenl  time,  complete  relief.  I 
have  always  performed  the  operation  on  the  nerve  at  aboul  the  junc- 
tion of   the  middle  ami    Lower  third-,  that    being  the   point  at   which  it 

is  more  readily  reached.  I  make  an  incision  four  or  I've  Inches  ill 
length  through  the  skin  and  aponeurosis,  ami  expose  the  nerve.     I 

tlun  pass  under   it    an  ivory  paper-knife,  and    gradually  lilt    the   nerve 
from  the  bottom  of  the  wound,  Stretching   it    to   the  extent  of  I  hi. 
four   inches,  while  making   the   traction   a-    far   a-    possible    in  a  down- 
ward   direction.      In   the    lasl    case,    I    put    my    index  tinner   under   the 


848  DISEASES   OF  THE   PERIPHERAL   NERVOUS   SYSTEM. 

nerve,  and  lifted  it  out  of  the  thigh  with  much  more  ease  and  with 
less  risk  of  injury  than  before,  and  this  is  certainly  the  preferable 
procedure. 

The  operation  is  by  no  means  a  painful  one  ;  in  fact,  there  is  no 
pain  except  that  caused  by  the  preliminary  incision  through  the  skin. 
I  have  in  two  of  the  cases  omitted  to  use  anaesthetics  ;  but  in  the 
others  I  employed  the  ether-spray,  so  as  to  abolish  the  sensibility  of 
the  skin.  I  prefer  that  the  patient  should  be  sensitive  to  pain  while 
the  stretching  is  being  performed,  as  important  information  is  derived 
from  the  sensations,  the  object  being  to  carry  the  extension  to  the 
point  of  producing  very  decided  numbness. 

I  have  never  had  any  untoward  accident  follow  the  operation.  For 
several  days  subsequently  there  have  been  numbness  and  paresis  ;  but 
these  phenomena  have  gradually  disappeared,  and  without  being  fol- 
lowed by  a  return  of  the  pain. 

Compression,  as  a  remedy  for  neuralgia,  has  been  practised  to  a 
limited  extent,  but  is,  I  think,  worthy  of  more  extended  use.  Dowse  ' 
speaks  of  it  as  a  "  palliative  mode  of  treatment,  which  certainly  has 
some  advantages  ; "  but  I  have  in  several  cases  carried  it  to  a  much 
greater  extent  than  it  has  hitherto  been  employed. 

My  first  cases  were  two  of  neuralgia  of  the  testis,2  and  in  these  I 
subjected  the  spermatic  cord  to  pressure  strong  enough  to  break  up 
the  axis  cylinder  of  the  spermatic  nerve,  with  the  result  in  both  in- 
stances of  obtaining  complete  relief  from  the  most  agonizing  suffering. 
In  neither  case  has  there  been  any  return  of  the  disease  nor  loss  of 
genital  power.  I  made  use  of  an  apparatus  similar  to  a  lemon-squeezer, 
the  blades  of  which  could  be  brought  closely  together  by  means  of  a 
screw,  though  in  the  first  case  a  wooden  test-tube-holder  answered  the 
purpose.  Since  the  publication  of  these  cases,  I  have  employed  com- 
pression in  two  cases  of  sciatica,  using  a  tourniquet  and  an  ivory  ball 
for  the  purpose,  but  with  only  partial  success,  and,  in  one  case  of  severe 
supra-orbital  neuralgia,  with  complete  relief.  The  cases  in  which  com- 
pression is  applicable  are  limited,  of  course,  to  those  nerves  which,  by 
their  situation,  allow  of  strong  force  being  exerted  upon  them,  from 
the  fact  that  they  pass  over  bone,  and  to  those  which,  like  the  spermatic 
nerve,  admit  of  the  whole  tissue  being  compressed  between  two  op- 
posing hard  substances. 

1  Op.  df.,  p.  27. 

8  "Neuralgia  of  the  Testis,"  St.  Louis  Courier  of  Medicine,  May,  1880,  and  Neuro- 
logical Contributions,  No.  III.,  1881. 


SYPHILIS   OF   TOE   PERiriTERAL   NERVOUS   SYSTEM.  849 

CHAPTER  XL 

SYPHILIS  OF  THE  PERIPHERAL  NERVOUS  8Y8TEBL 

The  peripheral  nerves  are  often  the  seat  of  various  syphilitic  le- 
sions. They  maybe  compressed  even  to  the  extent  of  complete  destruc- 
tion by  a  syphilitic  neoplasm  developed  in  their  tract.  This  compression 
may  occasion  a  local  neuritis  with  consecutive  atrophic  degeneration, 
and  it  is  especially  apt  to  be  met  with,  in  connection  with  the  cranial 
nerves,  at  those  points  where  they  penetrate  the  dura  mater,  thickened 
by  a  syphilitic  infiltration.  Sometimes  this  leads  to  a  slight  compres- 
sion of  the  nerve,  the  sheath  of  which  is  thickened  and  the  nerve  itself 
softened  ;  and,  again,  to  anaemia  and  subsequent  atrophy. 

It  may  also  happen  that  a  gumma,  developed  in  the  vicinity  of  a 
nerve,  reaches  this  last  by  direct  growth.  This  is,  above  all,  liable  to 
occur  with  those  nerves  the  sheath  of  which  is  not  very  thick,  and  par- 
ticularly for  the  chiasma  of  the  optic  nerve.  Virchow,  Yon  Graefe, 
and  Heubner,  have  published  cases  of  the  kind. 

The  peripheral  nerves  may  also  be  the  seat  of  primitive  syphilitic 
lesions,  and  this  to  a  considerable  extent.  They  then  lose  their  rounded 
form  and  white  color,  and  present  the  appearance  of  reddish  cords 
formed  of  connective  or  fibroid  tissue.  At  other  times  they  have  been 
found  of  a  lardaceous  consistence,  or  rather  swollen  and  infiltrated  by 
a  reddish  or  yellowish-gray  substance.  These  alterations  have,  up  to 
the  present  time,  been  exclusively  observed  in  the  cranial  nerves. 

Finally,  in  the  instances  of  certain  neuralgic  patients,  peripheral 
paralyses  have  been  observed  which,  persisting  until  the  death  of  the 
individual,  have  presented,  on  the  most  thorough  examination,  no 
alteration  in  the  corresponding  nerves.  Syphilitic  lesions  limited  t<> 
a  single  nerve  are  always  manifested  by  grave  functional  troubles 
of  the  organs  supplied  by  the  affected  nerve,  with  integrity  of  neigh- 
boring organs.  Generally  these  lesions  concern  the  oculo-motor  nerve. 
i>  is  then  observed  before  the  movements  of  the  globe  of  the  eye 
are  affected.  Later  are  developed  external  strabismus,  exophthalmia, 
and  a  considerable  dilatation  of  the  pupil. 

When  the  syphilitic  lesion  all'eets  the  branches  of  the  facial,  the 
ordinary  symptoms  of   paralysis  of   this  nerve  are  observed.      When    il 

i-,  limited  to  the  abdacens,  there  are  internal  Btrabismus  and  diplopia. 
Paralj  us  of  the  muscles  of  mastication  of  one  side  has  been  noticed, 
consecutive  to  a  syphilitic  alteration  of  the  motor  branch  of  the  tilth 

of  the  coi-responding  side. 

Peripheral  motor  paralyses  of  syphilitic  origin  are  accompanied  \\  ith 
abolition  o'f  the  electric  excitability  of  the  branches  of  the  affected  oerv<  - 
(/ii  mssen),  ami  with  atrophy  of  the  corresponding  muscles  (Heubner). 

60 


850  DISEASES   OF   THE   PERIPHERAL   NERVOUS   SYSTEM. 

Syphilitic  lesions  may  concern  the  sensory  portion  of  the  trifacial, 
and  then  a  trifacial  neuralgia  is  developed,  the  origin  of  which  is  re- 
vealed by  its  nocturnal  exacerbations.  Hyperesthesia  sooner  or  later 
is  replaced  by  anaesthesia. 

Cases  cf  amblyopia  and  of  amaurosis,  yielding  to  the  action  of  spe- 
cific medication,  and  evidently  due  to  syphilitic  lesions  of  the  optic  nerve, 
have  been  published.   These  lesions  may  also  be  manifested  by  hemiopia. 

And  here  and  there  in  medical  literature  cases  are  found  recorded 
of  neuralgia  affecting  various  parts  of  the  body,  and  which  have  been 
promptly  cured  b\r  anti-syphilitic  treatment. 

Several  cases  of  syphilitic  anaemia  have  come  under  my  observation, 
in  which  there  was  no  reason  for  suspecting  a  central  lesion,  and  which 
were  promptly  cured  by  the  specific  treatment  recommended  in  other 
parts  of  this  work.  Cases  of  syphilitic  deafness,  due  to  alterations  of 
the  auditory  nerve  of  one  or  both  sides,  are  by  no  means  infrequently 
met  with,  and,  unless  taken  very  early  in  their  development,  by  the 
most  decided  anti-syphilitic  treatment,  are  apt  to  prove  intractable. 

Aphonia,  due  to  paralysis  of  the  laryngeal  muscles,  from  syphilitic 
alterations  of  the  communicating  branch  of  the  spinal  accessory  nerve 
or  the  recurrent  laryngeal  nerves,  is  not  a  very  uncommon  occurrence, 
and  is  usually,  if  subjected  to  treatment  before  the  excitability  of  the 
muscles  is  lost,  a  not  obstinate  affection. 

In  all  cases  of  syphilitic  paralysis,  in  addition  to  the  specific  treat- 
ment imperatively  demanded,  electricity  should  always,  if  possible,  be 
employed.  I  mention  this  last  fact  particularly,  because  I  am  led  to 
believe  the  idea  is  more  or  less  prevalent,  that  such  paralyses  require 
no  other  treatment  than  iodide  of  potassium  and  mercury.  I  have  re- 
peatedly found  in  cases  of  facial  paralysis,  clearly  syphilitic  in  charac- 
ter, that  the  electric  contractility  of  the  muscles  to  the  faradaic  cur- 
rent was  entirely  abolished,  and  that  the  galvanic  current  of  strong 
tension  was  necessary  to  excite  them  to  action. 


SECTION  V. 

DISEASES   OF  THE    SYMPATHETIC 
NERVOUS   SYSTEM.1 


CHAPTER   I. 

PATHOLOGY  OF  THE  CERVICAL  SYMPATHETIC. 

Wiiatevki:  idea  we  may  form  of  the  relations  of  the  great  sym- 
pathetic with  the  cerebro-spinal  axis,  and  of  the  nature  of  the  nervous 
functions  which  devolve  upon  it,  it  is  incontestable  that  the  nerve  ex- 
ercises an  immediate  influence  over  the  circulation,  calorification,  the 
tions,  and  the  nutrition  of  the  organs  to  which  it  is  distributed, 
and  over  the  elements  comprised  in  these  organs.  The  well-known 
experiment  of  Claude  Bernard,  which  consists  in  dividing  the  great 
cervical  sympathetic,  is  quite  adequate  to  exhibit  these  several  influ- 
ences.    As  a  consequence  of  such  a  section  there  result  : 

l.  A  very  apparent  dilatation  of  the  vessels  of  the  face  and  of  the 

ear  Of   the  corresponding  side,   and  which   amounts   to   a  well-marked 

congestion  of  these  parts.  Nothnagel  has  been  able  to  convince  himself , 
by  direct  observation,  that  these  vascular  troubles  affect  also  the  mem- 
branes and  the  encephalon  of  the  corresponding  side. 

Tlii->  dilatation  and  congestion  has  been  attributed  to  a  paralysis  of 
those  vaso-motor  fibres  of  the  sympathetic  which  give  tone  to  the 
sels.  It',  in  fact,  a  continuous  galvanic  current  be  passed  through  the 
peripheral  segment  of  the  divided  nerve,  we  see  the  vessels  resume 
their  normal  calibre,  and  at  the  same  time  the  phenomena  of  «•■  >mr*-~- 
tion  disappear. 

•J.    An  elevation  of   local    tempera!  ure,  especially  manifested    in    the 
natural    cavities   (auditory  canal,  QOStril,  mouth),  "ii    the   side  with   the 

1  Although  there  i-,  In  my  opinion,  fBcienl  data  relative  t<>  the  diaeaaea  "f  tho 

ithetic  nern  to  warrant  the  subject  being  full]  considered  in  a  systematic 

treatise  like  the  present,  I  have  thought  it  well  to  incorporate  Dr.  Labadii  I 
lent  lynopsia,  which  he  prepared  u  an  appendix  to  his  French  translation  of  this  work. 


852  DISEASES   OF   THE   SYMPATHETIC   NERVOUS   SYSTEM. 

section.    The  difference  of  temperature  between  one  side  and  the  other 
may  reach  as  much  as  1*5°  Centigrade. 

This  local  elevation  of  temperature  is  in  part  the  result  of  the  vas- 
cular congestion  determined  by  the  division  of  the  vaso-motor  nerves. 
We  know  that  the  temperature  of  the  peripheral  organs  is,  in  general, 
more  elevated  when  an  increased  quantity  of  blood  circulates  through 
them.  But,  as  this  local  rise  of  temperature  remains  after  all  trace  of 
vascular  congestion  has  disappeared,  it  has  been  supposed  that  the 
vaso-motor  nerves  exercised  a  direct  influence  over  the  function  of 
calorification  of  the  tissues  ;  that  the  vaso-motor  fibres  moderate  to  a 
certain  extent  the  nutritive  changes  of  the  organs  to  which  they  are 
distributed,  and  that,  moreover,  their  paralysis  causes  an  increase  in 
local  organic  combustion,  and  consequently  augmented  temperature. 
This  explanation  seems  to  be  all  the  more  reasonable,  from  the  fact  that, 
at  a  later  period,  the  local  elevation  of  temperature  is  succeeded  by  a 
burning  which  coincides  with  a  local  denutrition  of  the  tissues,  as,  for 
instance,  hemiatrophy  of  the  face.  At  the  same  time,  in  this  second 
period,  the  paralyzed  side  does  not  perspire,  or,  if  it  does,  perspires 
less  in  amount  and  less  frequently  than  the  sound  side  (Nicati),  while 
during  the  period  immediately  after  section  of  the  great  sympathetic 
we  observe  : 

3.  A  decided  diaphoresis  with  epiphora,  very  exactly  limited  to 
the  half  of  the  face  on  the  same  side  as  the  section. 

4.  Contraction  of  the  pupil  and  of  the  palpebral  opening,  with  re- 
traction of  the  globe  of  the  eye  on  the  same  side  as  the  section.  The 
contraction  of  the  pupil,  consequent  on  section  of  the  great  cervical 
sympathetic,  is  easily  explained  if  we  admit  that  this  nerve  has  control 
of  the  radiating  fibres  of  the  iris.  When  these  fibres  are  paralyzed, 
the  irian  sphincter,  no  longer  having  its  action  resisted,  contracts,  and 
the  pupil  is  diminished  in  size.  The  narrowing  of  the  palpebral  open- 
ing and  the  retraction  of  the  eyeball  have  been  attributed  to  paralysis 
of  the  orbital  muscle  of  Miiller  innervated  by  the  sympathetic,  and 
which  has  for  its  function  the  counteraction  of  the  straight  and  oblique 
muscles  of  the  eye,  and  of  preventing  these  muscles  from  drawing  the 
globe  backward. 

In  exciting  the  cervical  sympathetic  with  the  galvanic  current,  for 
example,  we  observe  a  certain  number  of  phenomena,  the  reverse  of 
those  which  result  from  its  section.  The  pupil  is  dilated,  the  eyelids 
are  widely  opened,  and  the  eyeball  is  projected  forward  ;  the  vessels 
are  contracted  and  the  circulation  restricted,  at  the  same  time  that  the 
temperature  is  diminished  in  the  corresponding  half  of  the  face.  The 
sensibility  is  diminished  on  the  same  side,  the  cornea  and  conjunc- 
tiva become  dry,  and  the  convulsions  caused  by  strychnia  are  less  pro- 
nounced than  on  the  opposite  side  (Waller,  Budge,  Claude  Bernard, 
and  Brown-Suquard). 


PATHOLOGY   OF  THE  NERVOUS  SYMr.YTHETIO  853 

These  experimental  results  accord  perfectly  with  those  obtained  by- 
clinical  observation  in  man.  In  a  certain  number  of  cases  of  trau- 
matic lesions  of  the  cervical  sympathetic,  published  during  the  last 
twenty  years,  there  have  been  mentioned  with  variable  frequency  the 
different  oculo-pupillary  and  vaso-motor  troubles  that  can  be  produced 
by  electrizing  the  sympathetic. 

Fourteen  cases  of  functional  troubles  of  the  cervical  sympathetic, 
consecutive  to  traumatic  lesions  of  this  nerve,  are  then  given  on  the 
authority  of  Weir  Mitchell,  Verneuil,  Seeligmuller,  Biirwinkel,  and 
others,  and  eleven  cases,  from  Panas,  Poiteau,  Eulenburg,  and  others. 
of  similar  derangements  from  the  presence  of  tumors  in  the  course  of 
the  nerve. 

Spontaneous  paralysis  of  the  cervical  sympathetic  is  also  known 
to  he  produced,  in  appearance  at  least,  although  not  very  often.  Six 
'1  from  Biirwinkel,  and  one  from  Kicati,  are  given  in  illustra- 
tion, in  all  of  which  there  were  vaso-motor  and  oculo-pupillary  troubles, 
limited  to  one  side,  and  in  all  respects  similar  to  those  following  sec- 
tion of  the  nerve. 

Besides  these,  there  may  be  functional  troubles  of  the  cervical  sym- 
pathetic, as  consequences  of  spontaneous  or  traumatic  lesions  of  the 
nervous  centres.  Barwinkel  gives  the  case  of  a  man  who,  having  the 
symptoms  of  bulbar  sclerosis,  presented  also  a  certain  number  of  phe- 
nomena peculiar  to  paralysis  of  the  cervical  sympathetic,  and  Seelig- 
muller that  of  a  woman  who  had  like  symptoms,  in  conjunction  with 
cerebral  haemorrhage. 

In  1869  M.  Rendu  collected,  in  a  very  interesting  memoir,  a  cer- 
tain number  of  cases,  in  which  traumatic  lesions  of  the  marrow  were 
Complicated  with  functional  troubles  of  the  cervical  sympathetic,  some 
attributable  to  paralysis,  and  others  to  excitation  of  the  nerve.  As  in 
the  instances  we  have  cited,  oculo-pupillary  derangements  were  mosl 
frequently  observed,  of  eighteen  civ,.-  referred  to  by  him  (fractures, 
luxations,  and  wounds  with  cutting  instruments),  implicating  the  cer- 

vic.il  sympathetic,  the  pupil  was  contracted  on  the  side  of  the  lesion 

f teen  times.  Sometimes  there  was  noted  a  narrowing  of  the  palpe- 
bral opening,  with  injection  of  the  conjunctiva,  the  face,  and  the  ear, 
and  elevation  of  temperature  in  the  same  parts.  These  vaso-motor 
troubles,  complicating  contraction  of  the  pupil  and  of  the  palpebral 
Opening,  were  particularly  marked  in  a  case  cited  by  M.  Rendu  from 
.M.    I  'iiow  n  N'(|iiard.' 

All  these  facts  sufficiently  demonstrate  that  the  superior  portion  "( 

the  spinal   axis  exercises   0V6r  ocular  innervation,  and   the  circulation 

and  the  calorification  of  the  cephalic  extremity,  an  influence  analogous 
to  that  of  the  great  cervical  sympathetic.     They  also  go  to  -how  that 

1  . 1  "  .  tome  \i\.,  1869,  p.  I B 


854  DISEASES   OF   TIIE   SYMPATHETIC   NERVOUS   SYSTEM. 

the  cervical  sympathetic  draws  a  great  part  of  its  nervous  action  from 
the  superior  segment  of  the  spinal  cord. 

A  like  inference  must  also  be  drawn  from  the  fact  that  in  locomo- 
tor ataxia  there  are  similar  disturbances  in  the  movements  of  the  pupils 
— disturbances  which,  as  we  have  already  seen,  are  among  the  earliest 
symptoms  of  the  spinal  affection. 

CONCLUSIONS. 

From  a  consideration  of  the  preceding  facts,  we  see  that  of  four- 
teen cases  of  traumatic  lesion  of  the  region  of  the  neck,  in  which  there 
were  also  functional  troubles  of  the  cervical  sympathetic,  ten  were  of 
the  form  of  paralysis,  while  in  four  only  were  the  symptoms  indicative 
of  irritation.  In  compression  of  the  cervical  sympathetic  by  tumors, 
of  eleven  cases,  eight  were  manifested  by  paralysis,  and  three  only  by 
irritation.  And  in  instances  of  the  compression  of  the  sympathetic  by 
intra-thoracic  tumors,  functional  troubles  affected  the  cervical  portion 
of  the  nerve,  and  they  were  always  of  a  paralytic  character. 

The  troubles  consist,  for  the  most  part,  of  oculo-pupillary  phenom- 
ena— constriction  or  dilatation  of  the  pupil  and  of  the  palpebral  open- 
ing. More  rarely  circulatory  and  calorific  troubles  (such  as  congestion 
with  local  elevation  of  temperature  in  the  case  of  paralysis  of  the 
great  sympathetic,  paleness  of  the  countenance,  with  lowering  of  tem- 
perature in  the  case  of  irritation  of  the  nerve),  and  derangement  of  the 
secretions,  are  noted.  In  one  case,  the  compression  of  the  sympathetic 
by  one  of  the  lobes  of  an  hypertrophied  thyroid  gland  caused  no  other 
symptom  than  an  increased  secretion  of  sweat. 

In  a  certain  number  of  cases  of  traumatic  lesions  of  the  cervical 
sympathetic,  oculo-pupillary  and  vaso-motor  troubles  are  complicated 
with  an  atrophy  of  the  half  of  the  face.on  the  same  side  as  the  lesion. 
M.  Nicati  is  therefore  wrong,  in  his  rather  theoretical  description  of 
the  course  of  the  morbid  phenomena  in  cases  of  paralysis  of  the  great 
sympathetic,  in  considering  hemiatrophy  as  a  symptom  of  the  late 
period  of  the  disorder.  In  Case  III.,  hemiatrophy  was  one  of  the  phe- 
nomena of  irritation  of  the  sympathetic,  along  with  mydriasis,  paleness 
of  the  corresponding  side  of  the  face,  and  depression  of  temperature 
of  the  external  auditory  canal ;  and,  in  Case  VII.,  hemiatrophy  was 
developed  a  short  time  after  the  accident  which  caused  the  paralysis  of 
the  sympathetic. 

We  also  notice  that,  in  a  case  reported  by  Willebrand  (XVII.),  the 
use  of  iodine  preparations  caused,  not  only  the  disappearance  of  a  sub- 
clavicular strumous  tumor,  but  also  the  paralysis  of  the  cervical  sym- 
pathetic, which  had  justly  been  attributed  to  the  compression  of  the 
nerve  by  the  growth.  M.  Verneuil  has  seen  the  dilated  pupil  of  an 
individual  who  was  the  subject  of  a  cervical  abscess  resume  its  normal 
diameter  when  the  abscess  was  opened  and  emptied  of  its  contents. 


NEUROSES   OF   THE   CERVICAL   SYMPATHETIC.  855 

A  like  fact  has  come  under  my  own  observation.  It  occurred  in  a 
lady  upon  whom  I  had  operated  for  a  multilocular  cystic  tumor  of  the 
neck,  immediately  over  the  sympathetic  nerve.  After  the  excision,  a 
large  cavity  was  left,  which  was  filled  with  lint  for  the  purpose  of 
arresting  the  oozing  of  blood.  In  a  short  time  symptoms  of  irritation 
of  the  pneuraogastric  and  sympathetic  nerves  were  developed.  These 
consisted  of  vomiting,  irregular  respiration,  and  great  disturbance  of 
the  heart's  action  (pneumogastric),  and  dilatation  of  the  pupil  and 
paleness  of  the  face  on  the  side  of  the  lesion  (sympathetic).  On  re- 
moving the  pledgets  of  lint,  both  series  of  phenomena  at  once  ceased. 


CHAPTER  II. 

NEUROSES  OF  THE  CERVICAL  SYMPATHETIC. 
MIGRAINE,    OR    IIEMICRAXIA. 

Lately  certain  neuroses  have  been  regarded  as  functional  troubles 
of  the  sympathetic  nerve.  Sometimes  they  are  apparently  the  result  of 
an  irritative  action,  and,  again,  of  a  paralytic  state  of  various  parts  of 
this  nerve. 

By  migraine,  or  hemicrania,  we  understand  a  painful  paroxysmal 
affection,  limited  to  one  half  of  the  head,  and  which  is  accompanied  by 
oculo-pupillary.  circulatory,  and  calorific  disturbances,  which  serve  to 
distinguish  the  painful  crises  in  question  from  supra-orbital,  temporal, 
or  occipital  neuralgias,  with  which  they  are  often,  nevertheless,  con- 
founded. 

Tii<'  attacks  are,  in  general,  of  irregular  succession,  and,  in  the  inter- 
vals between  them,  the  patient  is  apparently  entirely  well.  Usually, 
ilir  approach  of  a  paroxysm  is  announced  by  prodromatic  phenomena. 
The  patienl  is  irritable,  and  indisposed  for  mental  labor.    Among  other 

premonitory  Bigne   may  he   mentioned  yawning,  noises   in  the  ears,  the 

presence  <>f  dark  specks  (scotoma)  in  the  visual  field,  sneezing,  a  feeling 
of  constriction  in  the  side  of  the  head  to  be  attacked,  and,  above  all, 
aausea. 

The  hemicrania]  pain  generally  attains  to  its  highest  point  in  a 
gradual  manner.  More  frequently  it  is  Beated  in  the  left  than  iii  the 
righl  side  of  the  head,  hut  it  may  in  the  same  patient  attack  each  side 

alternately.  The  pain,  instead  of  being  lancinating  or  boring,  as  in 
the  case  of  neuralgia,  is  rather  constricting,  and  covers  a  great  area. 
Ordinarily,  it   i-  sharpest   in  the  frontal,  occipital,  or  parietal  region. 

There  are  no  painful  points,  :is  in  neuralgia.     Often,  however,  pressure 

over  a  circumsoribed  part  of  the  parietal  region  causes  an  exacerbation 


856  DISEASES  OF   THE   SYMPATHETIC   NERVOUS   SYSTEM. 

of  the  hypersensitiveness  to  pain.  Ordinarily,  also,  pressure  over  the 
superior  or  middle  cervical  ganglion  is  painful.  More  rarely,  a  like 
effect  follows  strong  pressure  made  over  the  spinous  processes  of  the 
cervical  and  first  dorsal  vertebrae.  We  may  state,  also,  that  Dr.  Berger 
has  shown  with  the  resthesiometer  that  a  certain  degree  of  tactile  hyper- 
esthesia exists  on  the  half  of  the  face  corresponding  with  the  affected 
side. 

In  addition  to  the  pain,  we  have  to  call  attention  to  other  prominent 
symptoms  which  are  habitually  present.  These  are  nausea  and  vomit- 
ing, hallucinations,  such  as  noises  in  the  eai*s,  circles  of  fire  in  the  eye- 
sight, and  a  disagreeable  taste  in  the  mouth.  Then  come,  also,  oculo- 
pupillary  and  vaso-motor  troubles,  which,  according  to  Eulenburg,  may 
be  of  two  distinct  clinical  types  : 

1.  Sometimes  it  is  observed  that,  during  the  duration  of  the  parox- 
ysm, the  pupil  on  the  affected  side  is  manifestly  dilated,  at  the  same 
time  that  the  ball  of  the  eye  is  retracted  to  the  bottom  of  the  orbital 
cavity.  The  corresponding  half  of  the  face  and  the  ear  of  the  same 
side  are  of  an  extreme  paleness,  and  the  temporal  artery  is  contracted 
and  forms  a  hard  cord,  much  less  prominent  than  that  of  the  oppo- 
site side.  The  temperature  of  the  external  auditory  canal  is  lower 
than  that  of  the  same  side — 0.4°  to  0.6°  C.  It  is  also  a  matter  of 
demonstration  that  every  cause  capable  of  diminishing  the  flow  of 
blood  to  the  painful  half  of  the  head  augments  the  suffering.  This 
is  especially  shown  if  the  carotid  artery  of  the  affected  side  be  com- 
pressed.    If  the  opposite  carotid  be  compressed,  the  pain  is  lessened. 

Toward  the  end  of  the  paroxysm,  when  the  hemicranial  pain  is  on 
the  point  of  beginning  to  disappear,  the  pupil  contracts,  the  pallor  of 
the  face  and  of  the  ear  of  the  painful  side  is  replaced  by  a  state  of 
congestion,  with  sensation  of  heat,  elevation  of  local  temperature,  injec- 
tion of  the  conjunctiva,  epiphora,  and  acceleration  of  pulse.  The 
painful  crisis  very  often  ends  by  the  appearance  of  a  profuse  sweat,  an 
abundant  flow  of  urine,  or  by  a  diarrhoeal  flux.  As  is  readily  per- 
ceived, the  symptoms  of  this  form  of  hemicrania  recall  to  our  minds 
the  results  due  to  traumatic  or  experimental  excitation  of  the  cervical 
sympathetic.  It  is  for  this  reason  that  it  has  been  proposed  to  give  to 
this  clinical  form  the  name  spasmodic  or  sympathico-tonic  hemicrania. 

2.  At  other  times  the  oculo-pupillary  and  vaso-motor  disturbances 
are  presented  with  characteristics  absolutely  the  reverse  of  those  to 
which  we  have  called  attention.  During  the  duration  of  the  paroxysm 
the  pupil  is  contracted,  as  is  also  the  palpebral  opening,  and  the  upper 
eyelid  droops.  The  face  and  ear  of  the  affected  side  are  injected,  and 
the  temperature  of  the  external  auditory  canal  exceeds  by  0.2°  to  0.4° 
C.  that  of  the  unaffected  side.  The  dilated  temporal  artery  beats  with 
force,  the  pulse  is  often  rendered  slower,  and  compression  of  the 
carotid  artery  of  the  painful  side  diminishes  the  pain.     Toward  the 


NEUROSES   OF   TIIE   CERVICAL   SYMPATHETIC.  srr, 

end  of  the  paroxysm  these  symptoms  generally  change.  This  form  of 
hemicrania  has  been  called  angio-paralytic  or  neuro-paralytic,  for  the 
reason  that  the  symptoms  which  constitute  a  paroxysm  are  exactly 
like  those  which  are  observed  on  section  of  the  great  cervical  sympa- 
thetic. 

Cases  have  been  reported  in  which  the  paroxysms  have  in  the  same 
patient  alternated  in  character — the  angio-paralytic  appearing  at  one 
time,  and  the  angio-spastic  at  another.  At  other  times,  the  hemicranial 
pain  constitutes  the  only  phenomenon  of  the  >n,  the  vaso-motor 

and  oculo-pupillary  troubles  being  entirely  absent. 

Ae  we  have  already  remarked,  the  paroxysms  of  angiospastic  and 
angio-paralytic  hemicrania  realize  with  the  utmost  exactness  the  mor- 
bid picture  observed  as  the  consequence  of  excitation  or  section  of  tin- 
cervical  sympathetic  nerve.  On  this  account,  certain  authors,  ami  par- 
ticularly Du  Bois-Reymond,  and  Eulenburg,  in  Germany,  have  not  hesi- 
tated to  invoke  the  mechanism  in  question  in  the  pathogeny  of  this 
painful  neurosis.  Angio-spastic  hemicrania  should,  accordingly,  have 
its  point  of  departure  in  a  periodical  irritation  of  the  great  sympathetic 
or  of  the  Bnperior  cervical  ganglion  ;  while  a  paralytic  condition  of 
these  organs  is  considered  to  be  the  cause  of  angio-paralytic  hemicrania. 

But  this  theory  has  met  with  opposition.  Thus  Drs.  Brown-Sequard 
and  Althaus  have  insisted  that  vascular  spasm  of  one  half  of  the  ence- 
phalic extremity  would  naturally  produce  ansemia  of  the  correspond- 
ing cerebral  hemisphere,  and  that  such  a  disturbance  of  the  circulation 
would  cause  epileptiform  convulsions  of  the  opposite  half  of  the  body. 
But  Eulenburg  remarks  with  much  reason  that  electrization  of  the 
central  extremity  of  the  diseased  cervical  sympathetic  produces  a 
cular  Bpasm  on  the  corresponding  side  of  the  bead  and  of  the  encepha- 

lon,  and  al    the  same   time  the  oculo-pupillary  and  vaso-motor  troubles 

described  above.  Moreover,  the  like  results  are  obtained  in  cases  of 
traumatic  irritation  <»t'  the  great   cervical  sympathetic.     Finally,  this 

author  asks  whether  irritation  of  the  nerve   in  question  does  not  rather 

induce  a  partial  ischemia,  limited  to  certain  regions  of  the  encepha- 
lon,  than  generalized  ansemia  extending  over  the  half  of  this  organ. 

Bui   if  the  Bpasm  or  relaxation  of  the  vessels  of  a  half  of  the  oeph.il- 

ic  extremity,  when  compared  with  the  like  conditions  obtained  bj 
perimental  physiology,  enables  us  to  account   for  the  vaso-motor  and 
oculo-pupillary  disturbances  observed  in  the  course  of  one  or  the  other 

form    of    hemicrania,  how   are    we    to   explain    the    principal    symptom, 

pain?  Are  we  to  place  the  seal  in  t  he  nen  on-  ramifioations,  which  the 
trigeminus  supplies  to  the  dura  mater,  or  in  those  which  the  Bame 
ierve,  as  well  as  the  sympathetic,  sends  to  the  vascular  network  of 
the  pia  mater?  According  t • »  Da  Bois-Reymond,  the  pain  in  the 
angio-spa  tic  form  has  no  other  cans,'  than  the  tetanic  contraction 
of  the  non-striated  fibres  of  the  vascular  walls.     It  has  it-,  analogue 


858  DISEASES   OF   TIIE   SYMPATHETIC   NERVOUS   SYSTEM. 

in  cases  of  contractions  of  the  muscles  of  the  calf  of  the  leg,  of  the 
uterus,  and  of  the  intestinal  walls,  either  one  of  which  produces  pain- 
ful sensations.  This  explanation,  which  does  not  lack  ingenuity,  can 
only  at  most  be  applied  to  one  of  the  forms  of  hemicrania. 

Eulenhurg  has  proposed,  in  place  of  this  theory,  one  of  his  own, 
which  he  thinks  is  applicable  to  all  cases.  In  his  opinion,  hemicranial 
pain  has  its  point  of  departure  in  a  disturbance  of  the  circulation, 
either  as  annemia  or  hypersemia  of  the  affected  cerebral  hemisphere. 
This  circulatory  trouble  acts  as  a  veritable  irritant  to  the  sensory 
nerves  of  the  skin,  the  scalp,  and  the  meninges,  and  thus  develops  the 
painful  paroxysms  of  migraine. 

By  some  pathologists,  and  notably  Anstie  '  and  Clifford  All  butt,2 
migraine  has  been  regarded  as  a  neuralgic  affection  of  the  ophthal- 
mic branch  of  the  fifth  nerve,  the  latter,  however,  contending  for  the 
simultaneous  existence  of  cephalic  and  abdominal  complications.  This 
view  must,  I  think,  give  way  to  that  which  ascribes  the  main  causative 
influence  to  derangement  of  the  sympathetic  nerve. 

But  my  own  experience  does  not  lead  me  to  the  extent  of  accept- 
ing the  theory  of  Du  Bois-Reymond,  that  migraine  is  always  the  re- 
sult of  a  contraction  of  the  vessels — a  tetanus,  in  fact,  of  the  muscular 
coat  ;  nor  to  that  of  Mollendorf,3  according  to  which  it  is  always  due 
to  a  relaxation  of  the  vessels  and  an  increased  flow  of  blood  to  the 
brain.  I  am  quite  sure,  with  Eulenburg  and  Gutman,4  that  there  are 
cases  under  each  of  these  heads,  a  view  which  is  also  held  by  Berger.6 
Clinical  experience  is  so  decidedly  in  favor  of  this  latter  theory,  that  it 
appears  impossible  to  resist  the  conclusion  to  which  it  leads,  for  we 
find  in  practice  that  those  agents  which  diminish  the  tone  of  the  ar- 
teries cure  some  cases  and  aggravate  others,  while  those  remedies 
which  increase  the  arterial  tension  are  sometimes  efficacious  and  again 
injurious.  The  importance,  therefore,  of  making  an  exact  diagnosis 
of  the  forms  of  hemicrania  with  which  we  have  to  deal  cannot  be 
over-estimated  ;  but,  with  this  end  in  view,  not  only  should  inquiries 
be  instituted  relative  to  the  appearance  of  the  face,  as  regards  pallor  or 
redness  and  temperature,  the  oculo-pupillary  phenomena,  and  the  ef- 
fects of  such  remedies  as  may  previously  have  been  given,  but  oph- 
thalmoscopic examination  should  be  made,  if  possible,  at  different 
times  throughout  the  duration  of  the  paroxysm.  Mollendorf  observed 
that,  in  the  eye  of  the  affected  side,  the  fundus  was  of  a  bright  scar- 

1  "Neuralgia  and  the  Diseases  that  resemble  it,"  New  York,  1872,  p.  154. 

2  "  On  Migraine,"  Practitioner,  January,  1873. 

3  "  Uber  Hemicranie,"  Virchow's  Archiv,  Band  xli.,  p.  385. 

4  "Physiology  and  Pathology  of  the  Sympathetic  System  of  Nerves,"  translated  by 
Napier,  London,  1879,  p.  65. 

5  "Zur  Pathogenesc  der  Hemicranie,"  Virchow's  Archiv,  Band  lix,  II.  3  and  4,  1S74  ; 
also,  translation  by  Dr.  Gradle,  Chicago  Journal  of  Nervous  and  Menial  Diseases,  July, 
1874,  p.  296,  it  scq. 


NEUROSES   OF   THE   CERVICAL   SYMPATHETIC.  859 

let  color,  while  in  that  of  the  opposite  side  it  remained  of  its  normal 
brownish-red  hue.  I  have  not  only  frequently  noticed  this  appear- 
ance, but  in  other  cases  have  witnessed  a  pallor  of  the  fundus  of  the 
eye  on  the  affected  side,  only  to  be  explained  on  the  hypothesis  of  a 
diminished  amount  of  blood  being  in  the  encephalic  arteries  on  that 
Bide.  Information  of  important  diagnostic  value  can  also  be  obtained 
by  observing  the  effect  of  pressure  on  the  carotid  artery  during  the 
period  of  the  seizure.  In  the  anaemic  form  the  procedure  causes  an 
aggravation  of  the  Buffering,  while  in  the  hypersBmic  it  produces  prompt 
mitigation  of  the  pain  and  other  attendant  phenomena. 

Treatment. — The  vaso-motor  theory  of  migraine  has  been  in  part 
our  guide  to  the  treatment,  and  the  efficacy  of  the  means  employed  has 
ii  us  data  for  successful  management,  which,  though  based  on  em- 
piricism, are  of  great  value. 

Thus,  it  was  reasonable  to  conclude,  a  priori,  that  the  functional 
trouble  of  the  great  sympathetic  could  be  alleviated  by  the  electric 
current,  and  experience  has  established  the  wisdom  of  this  deduction. 
J.  Benedict,  Frommhold,  Freber,  Rosenthal,  and  Althaus,  as  cited  by 
Eulenburg,1  have  published  oases  of  migraine  treated  with  mi.tcss  by 
galvanization  of  the  great  sympathetic  Hoist,1  basing  his  procedure 
on  the-  polar  theory  of  Brenner,  advises  the  following  method  tor  tin 
galvanization  of  the  cervical  sympathetic  :  In  the  angio-spastio  form 
of  migraine,  in  which  it  is  necessary  to  moderate  the  irritability  of  the 
nerve,  a  current  from  ten  to  fifteen  elements  should  he  employe'], 
the  positive  pole  being  applied  <>ver  the  sympathetic,  and  the  negative 

held  in  the  hand  of  the  same  side.      Each  8&anCi    should    [asl    for   from 

two  to  three  minutes.  In  the  angio-paralytio  form,  the  negative  pole 
should  be  applied  over  the  course  of  the  nerve.  To  obtain  a  more 
energetic  action  on  the  nerve,  the  current  should  be  frequently  inter- 
rupted, or  even  reversed. 

In  point  of  fact,  however,  according  to  my  experi<  nee,  i:  is  a  mat- 
ter <>t'  no  consequence  what  the  direction  of  the  current  is  in  either 
form  of  the  disease.  One  pole  should  be  applied  over  the  nerve  in  the 
neck,  and  the  other  placed,  preferably,  on  the  pit  of  the  stomach,  ami 
the  action  continued  for  from  two  to  live  minutes. 

Frommhold,'  how<  \«r,  advises  the  ose  of  the  faradic  current  in  the 
affection,  and  Freber  '  agrees  with  him  in  this  practice.  In  my  experi- 
ence, it  cannot  be  compared  in  efficacy  to  the  galvanic  current,  and, 
indeed,  I  have  often  found  it  to  aggravate  the  pain.     When  it  is  used, 

1  Ziemssen's  "  II  in  Ibucb  tier  tpeciallen  Pathologic  and  Therepie,"  Ban  1  MI..  | 

'.  and  Patholog)  of  the  Sympathetic  System  ol  '  nborg 

itman,  Napier'a  translation,  London,  1^7'.',  p.  7". 

rpater  media  Zeitschrift,"  Muni  II.,  1871,  p.  861. 
!'.■   ktigrnine  mi  I  ilnv  Efandlung  darcfa  Elccti 
1  " Compendium  der  Electrotherapies"  Wlen,  Ik> 


800  DISEASES   OF   THE   SYMPATHETIC   NERVOUS   SYSTEM. 

the  interruptions  should  be  very  rapid,  and  the  intensity  as  great  as 
the  patient  can  endure. 

During  the  intervals  between  the  attacks,  galvanism  should  still  be 
employed  as  a  remedial  agent,  with  the  view  of  altering,  if  possible, 
the  tendency  to  the  occurrence  of  paroxysms  ;  but  it  is  then  not  the 
chief  therapeutical  agent.  Indeed,  I  am  not  disposed  to  think  that  it 
is  ever  entitled  to  this  distinction. 

In  my  own  practice,  during  the  existence  of  the  paroxysm,  I  first 
endeavor  to  ascertain  the  character  of  the  seizure.  If  it  is  of  the  angio- 
spastic vai'iety,  that  is,  the  form  in  which  the  calibre  of  the  blood- 
vessels is  diminished,  I  administer  a  large  dose  of  morphia,  say  the 
quarter  or  third  of  a  grain,  by  hypodermic  injection,  and  at  the  same 
time  cause  the  patient  to  take  repeated  inhalations  of  the  nitrite  of 
amyl.  Latterly,  I  have  sometimes,  for  the  nitrite  of  amyl  by  inhala- 
tion, substituted  the  internal  administration  of  this  drug  in  doses  of 
from  one  to  four  or  five  drops,  or  of  glonoine  in  doses  of  the  one  hun- 
dredth of  a  grain. 

If  there  is  reason  to  suspect  the  influence  of  malaria  in  the  produc- 
tion of  the  disease,  I  give  a  large  dose  (from  twenty  to  forty  grains) 
of  the  sulphate  of  quinine,  instead  of  the  morphia  and  other  substances 
mentioned.  Experiments  which  I  performed,  in  conjunction  with 
Roosa,1  show  that  under  the  action  of  this  agent  the  amount  of  blood  in 
the  brain  is  increased.  As  these  experiments  bear  directly  on  the  ques- 
tion at  issue,  I  may  be  permitted  to  quote  them  here.  It  is  well  known 
that  the  obvious  phenomena  which  result  from  a  large  dose  of  quinia  are 
such  as  indicate  an  increased  flow  of  blood  to  the  brain.  The  redness 
of  the  face,  the  injection  of  the  conjunctivas,  the  noises  in  the  ears,  the 
sensation  of  distention  or  fullness  or  constriction  felt  in  the  head,  are 
all  so  many  indications  of  cerebral  hypersemia.  Still,  I  was  desirous 
of  settling  the  matter  by  direct  experiment  and  the  employment  of 
those  instruments  of  precision  which  the  progress  of  science  has  put  at 
our  disposal. 

With  this  object  I  resolved  to  take  quinine  myself,  and  to  have 
my  friend  Dr.  Roosa,  whose  abilities  as  an  ophthalmologist  and  aurist 
are  indisputable,  examine  the  fundus  of  the  eye  and  the  tympanum 
before  the  ingestion  of  the  quinine  and  during  the  continuance  of  its 
effects. 

The  experiment  was  made  on  the  evening  of  May  7th,  and  I  sub- 
join his  report  in  his  own  words  : 

"  Vision  normal —  M 

Refraction emmetropic. 

Pulse 90 

111  The  Influence  of  the  Disulphate  of  Quinine  over  the  Intra-Cranial  Circulation," 
Psychological  and  Medico- Legal  Jou^ned,  October,  18*74. 


NEUROSES   OF   THE   CERVICAL   SYMPATHETIC.  861 

"  Ocular  conjunctivae  white,  decidedly  free  from  hyperemia.  Pal- 
pebral congested  at  outer  and  inner  canthus.  Has  no  tinnitus  annum. 
Membrana  tympani  entirely  free  from  evidence  of  vessels.  No  conges- 
tion along  handle  of  malleus. 

"Ophthalmoscopic  examination  of  both  eyes  reveals  a  remarkably 
clear  optic  papilla  on  both  sides.  Arteries  and  veins,  vertical  and  hori- 
zontal vessels,  clearly  cut,  and  whole  papilla  sharply  defined,  rather 
paler  than  congested. 

"  Took  grs.  x.  sulphate  of  quinine  at  8.30  p.  m.  At  9  p.  m.  ocular 
conjunctiva  is  congested  at  outer  and  inner  canthus.  Palpebral  con- 
junctiva markedly  congested  over  'whole  surface.  No  change  in  optic 
papilla?  or  in  dram-heads. 

"9.15.  .Surface  of  optic  papillae  pinkish  ;  arterial  vessel-  seem  more 
distinct  ;  no  change  in  appearance  of  drum-heads  ;  no  tinnitus  aurium. 

"10.  Head  feels  full;  left  ear  rings;  auricles  burn;  face  is  de- 
cidedly flushed  ;  auricles  red,  especially  lobe  of  right,  where  there  is  a 
localized  congestion  that  is  so  marked  as  to  resemble  an  eochymosis. 
There  is  now  a  vessel  along  each  malleus  ;  optic  papilla  are  pinkish. 
Pulse  84  and  fuller. 

"10.30.  Right  drum-head  is  very  much  injected  along  handle  of 
malleus  and  upper  margin.  Left  less  so,  but  yet  injected.  Both 
papilla  very  pink,  left  more  so  than  right.  Face  flushed,  eyes  Buffused, 
ocular  conjunctiva  decidedly  congested.  Slight  headache;  tinnitus  in 
both  ears. 

"11.  Redness  of  auricles  diminishing,  especially  the  circumscribed 
spot  on  the  lobe  of  left  one  ;  face  still  flashed  ;  tinnitus  continue-  :  DO 
headache  ;  feels  exhilarated.  Dram-heads  still  injected  along  malleus  ; 
not  more  so,  however,  rather  less  ;  optic  papilla*  have  a  decidedly  pink- 
ish hue;  do  more  lateral  vessels  Been,  however;  right  is  especially 
pink.  Tinnitus  still  continues;  vision  normal.  No  further  observa- 
tions were  made.'1 

That  the  phenomena  indicated  cerebral  hyperemia  is  b<  If-evident, 
and  therefore  do  further  remarks  on  the  point  are  Decessary. 

But  it  was  possible  to  determine  the  question  with  even  greater 
certainty. 

I  therefore  trephined  a  medium-sized  dog,  and  screwed  a  cephalo- 
bsemometer  into  the  opening  in  the  Bkull  made,  by  the  trephint .  so  that 

the  fluid  in  the  glaSS  tube  BtOOd  at   /.to. 

I  then  introduced  into  the  cellular  tissue  of  the  abdomen  ten  grains 
of  sulphate  of  quinine,  dissolved  in  water  acidulated   with  sulphuric 

acid.      This  was  done  at  8.80  o'clock  r.  m. 

At  ."..:;.")  the  tluid  had  risen  one  degree  on  the  scale  I      fo  inch). 

It    continued    to   rise   gradually  but    steadily,  till   at    I.IOit   had    pa 

over  ten  degrees  (  =  l  inch  of  the  tube).     At  L80,  one  hour  after  the 

injecti >f  the  quinine,  the  fluid  was  at  j    15  .     It  continued  at  this 


862  DISEASES   OF   THE   SYMPATHETIC   NERVOUS   SYSTEM. 

point  till  5.10,  when  it  began  to  fall,  and  at  8.15  was  at  zero.  It  re- 
mained stationary  for  over  an  hour,  at  no  time  falling  to  the  minus 
division  of  the  scale. 

The  stage  of  excitement  scarcely  lasted  fifteen  minutes.  It  was 
succeeded  by  a  state  of  sedation  during  which  the  salivation  was 
excessive,  and  the  animal  appeared  very  much  as  if  under  the  influence 
of  a  full  dose  of  alcohol.  As  the  normal  condition  of  the  dog  was 
regained,  the  fluid  fell  in  the  tube,  and  reached  the  zero  almost  simul- 
taneously with  the  disappearance  of  the  symptoms  of  intoxication. 

I  repeated  the  experiment  on  different  days  with  variable  doses  of 
quinine — from  two  grains  to  fifteen — in  all,  four  times,  and  invariably 
with  the  result  of  a  steady  rise  of  the  fluid  in  the  tube  as  the  effect  of 
the  drug  increased,  and  its  fall  to  the  zero  as  the  influence  wore  off. 
At  no  time  did  the  fluid  reach  a  lower  point  than  that  at  which  it 
stood  before  the  administration  of  the  quinine. 

I  think  the  several  experiments  detailed  in  this  memoir  show  con- 
clusively that  the  influence  of  the  sulphate  of  quinine  over  the  intra- 
cranial circulation  is  that  of  causing  hyperemia  and  congestion. 

So  far  as  I  am  aware,  there  are  no  experiments  on  record  such  as 
I  have  described,  and  the  theory  that  the  sulphate  of  quinine  produces 
cerebral  anromia  is  one  not  based  on  fact,  but  solely  on  the  interpreta- 
tion of  certain  phenomena  to  accord  with  a  previously  formed  hypothe- 
sis of  its  physiological  action. 

I  think,  therefore,  that  quinia  may  properly  be  regarded  as  an 
antagonist  to  the  tetanic  condition  existing  in  the  angio-spastic  form 
of  migraine — in  addition  to  its  anti-periodic  virtue.  Experience  shows 
that  the  effect  is  almost  always  an  abrupt  cutting  short  of  the  parox- 
ysm, especially  if  the  nitrite  of  amyl  be  inhaled  repeatedly,  and  to  the 
extent  of  obtaining  the  full  physiological  effect  of  the  drug. 

In  this  angio-spastic  form  of  migraine,  the  treatment  in  the  intervals 
between  the  paroxysms  should  consist  of  the  administration  of  some 
one  of  the  bromides  (sodium,  potassium,  calcium,  or  ammonium)  in 
doses  of  at  least  fifteen  grains  three  times  a  day  ;  for,  although  the 
influence  of  these  remedies  is  to  diminish  the  amount  of  blood  in  the 
brain,  they  are  antagonistic  to  all  forms  of  muscular  spasm.  Either 
one  of  those  mentioned  may  be  advantageously  given,  in  combination 
with  pepsin  and  charcoal,  as  recommended  under  the  head  of  "  cere- 
bral congestion."  If  this  method  of  treatment  be  followed  out  for 
two  or  three  months  with  firmness  and  persistency,  a  cure  may  reason- 
ably be  expected  in  the  great  majority  of  cases. 

The  treatment  during  the  paroxysm  in  the  angio-paralytic  form 
should  be  in  many  respects  the  very  opposite  of  that  proper  for  the 
angio-spastic  variety.  So  far,  however,  as  the  use  of  electricity  goes, 
no  change  is  necessary,  and  a  seizure  may  sometimes  be  cut  short  by 
the  galvanic  current,  from  ten  to  fifteen  elements. 


PATIIOLOGY   OF  THE   THORACIC   SYMPATHETIC.  8G3 

Cold  to  the  nape  of  the  nock  is  also  of  great  value,  and  compression 
of  the  carotid  on  the  affected  side  is  a  ready  and  prompt  means  of 
aborting  a  seizure  in  many  cases.  It  should  be  continued  in  some 
instances  for  an  hour,  or  even  longer,  and  then  the  pressure  should  be 
very  gradually  removed. 

For  internal  medication,  a  large  dose — thirty  or  forty  grains — of 
guarana  or  paullinia  sometimes  acts  like  a  charm,  as  does  also  strong 
coffee,  or,  better  still,  caffeine.  In  some  instances  strong  tea  will 
arrest  a  paroxysm  when  coffee  has  entirely  failed. 

Phenacetine  in  doses  of  from  ten  to  fifteen  grains,  which  can  be 
repeated  in  an  hour  if  necessary,  often  affords  prompt  relief.  Anti- 
pyrine  and  an tife brine  are  also  efficacious,  but  should  always  be  used  cau- 
tiously. These  remedies  not  only  frequently  fail  to  relieve  the  angio- 
spastic form  of  the  disease,  but,  on  the  contrary,  often  aggravate  it. 

But  it  is  not  wise  to  rely  entirely  on  any  one  of  the  measures. 
Cold,  compression  of  the  carotid,  and  galvanism,  should  he  employed 
at  the  same  time,  and  some  one  of  tin-  internal  remedies  administered, 
to  be  followed  by  another,  if  it  is  not  quickly  efficacious. 

After  the  paroxysm  is  over,  the  real  curative  treatment  should  be 
begun,  and  this  should,  as  in  the  other  form,  consist  of  the  bromides, 
but  in  combination  with  ergot.  1  usually  give  the  mixture  just  recom- 
mended, substituting  the  fluid  extract  of  ergol  wholly  or  in  part  for  the 
water,  and  continuing  the  treatment  for  several  months.  It  is  rare 
that  a  case  resists  this  form  of  management. 

Ami,  in  both  varieties,  attention  should  be  paid  to  the  hygiene  <>\' 
the  patient.  The  diet  should  he  simple  but  nutritious.  It  is  an  un- 
doubted fact  that  many  attacks  «»f  migraine  can  be  directly  traced  to 
indulgence  in  some  article  of  food  which  the  patient  know-  at  the  lime 
is  almost   certain    to    produce   a    seizure.      When    such    is   the   case,    an 

emetic  will  often  prevent  the  development  of  more  than  the  premoni- 
tory symptom  of  a  paroxysm. 


CHAPTER    III. 

PATHOLOGY  OF  Tin:  TEOBACHO  8TMPATm 

'I'm:  greal  thoracic  sympathetic  nerve  controls  the  vaso-motor  in- 
nervation of  the  superior  extremities,  the  trunk,  the  intra-thoracio 
as,  and  the  Bpinal  cord  Physiological  experimentation  upon  the 
ganglia  and  nerve  ..f  that  portion  of  the  greal  sympathetic  leads  to 
the  production  of  phenomena  analogous  t"  those  which  resull  from  the 
exoitation  and  pat  \  the  cervical  sympathetic.     Still,  up  to  the 

prevent  time,  we  have  at  our  disposal  only  a  small  number  of  instance  I 


864  DISEASES  OF  THE   SYMPATHETIC  NERVOUS  SYSTEM. 

of  vaso-motor  troubles  consecutive  to  lesions  of  the  thoracic  sympa- 
thetic, or  of  the  organs  to  which  it  is  distributed. 

We  have  seen,  from  the  cases  previously  given,  that  the  compression 
exercised  by  aneurisms  of  the  arch  of  the  aorta  and  of  the  thoracic 
portion  of  this  vessel  on  the  left  sympathetic  reacts  ordinarily  on  the 
cervical  sympathetic  of  the  same  side,  and  that  it  gives  rise  to  oculo- 
pupillary  and,  more  rarely,  to  vaso-motor  disturbances  of  the  corre- 
sponding side  of  the  face.  In  addition,  the  phenomena  in  question  were 
accompanied  in  a  certain  number  of  cases  by  an  acceleration  of  pulse, 
attributed  by  authors  to  the  compression  of  the  cardiac  filets  of  the 
great  sympathetic,  which  is  regarded  as  an  accelerator  nerve  of  the 
heart. 

Besides  these  vaso-motor  troubles  of  the  face  consecutive  to  com- 
pression of  the  thoracic  sympathetic  by  an  aneurism  of  the  aorta,  we 
must  note  the  redness  of  the  cheeks,  with  elevation  of  local  tempera- 
ture, observed  in  cases  of  pneumonia.  M.  Gubler,  who  has  specially 
studied  this  phenomenon,  has  called  attention  to  the  fact  that,  in  uni- 
lateral pneumonia,  the  redness  is  almost  always  limited  to  the  cheek  of 
the  corresponding  side.  On  the  other  hand,  it  is  established  from  the 
researches  of  M.  Lepine  that,  in  pulmonary  affections,  such  as  pneumo- 
nia and  tuberculosis  confined  to  one  lung,  there  exists  a  very  notable 
difference  of  temperature  in  the  two  sides  of  the  body — a  difference 
which  is  almost  always  in  favor  of  the  side  corresponding  to  that  of 
the  diseased  lung.  This  difference  may  amount  to  one  or  two  degrees 
Centigrade  at  the  extremities  of  the  limbs,  while  in  the  axillae  it  is  only 
a  few  tenths  of  a  degree. 

Quite  recently  Seeligmuller,  in  a  memoir  which  we  have  had  several 
occasions  to  cite,  has  called  the  attention  of  physicians  to  the  adhesions 
which,  in  the  case  of  lesions  of  the  summit,  the  lung,  and  its  pleural 
covering,  contract  with  the  thoracic  sympathetic.  This  morbid  condi- 
tion occasions  an  irritation  of  the  nerve,  to  which  a  state  of  paralysis 
succeeds.  In  the  same  way  we  account  for  the  congestive  spots  on  the 
cheeks  and  the  dilatation  of  the  pupils  observed  in  tuberculous  indi- 
viduals. In  a  certain  number  of  cases  of  unilateral  tuberculous  lesions, 
these  oculo-pupillary  and  vaso-motor  disturbances  are  limited  to  the 
side  corresponding  to  that  of  the  diseased  lung.  Thus,  in  the  instance 
of  a  woman  twenty-four  years  old  affected  with  catarrh  of  the  apex  of 
the  left  lung,  there  was  mydriasis  of  the  same  side.  In  a  man  thirty- 
eight  years  of  age,  who  had  pleuro-pneumonia  of  the  left  side  dur- 
ing ten  years  back,  and  a  large  cavity  in  the  apex  of  the  same  lung, 
it  was  observed,  six  months  before  the  fatal  termination,  that  at  times 
the  cheeks  and  the  ears,  markedly  on  the  right  side,  were  subject  to 
intense  congestion,  while,  simultaneously,  the  pupil  of  the  same  side 
was  contracted.  In  the  case  of  a  woman  sixty-seven  years  old,  affected 
with  pleuro-pneumonia  of  the  lower  lobe  of  the  right  lung,  there  was 


PATHOLOGY  OF  THE  ABDOMINAL  SYMPATHETIC.       865 

developed  a  bed-sore,  limited  to  the  buttock  of  the  same  side,  and  which 
took  four  months  to  heal.  Six  months  after  the  cure  of  the  pleuro- 
pneumonia, the  phenomena  of  paralysis  of  the  sympathetic — a  marked 
contraction  of  the  pupil  and  of  the  palpebral  opening  of  the  same  side — 
were  observed.  Indeed,  the  left  side  of  the  face  and  corresponding 
car  were  often  the  subjects  of  congestion,  which  made  a  marked  con- 
trast with  the  paleness  of  the  right  side  of  the  face.  Again,  in  a  man 
thirty-one  years  of  age,  who,  within  the  period  of  a  year,  had  Buffered 
from  five  attacks  of  pleuro-pneumonia  of  the  right  side,  the  pupil  of 
the  corresponding  side  was  contracted.  The  patient  had  himself  ob- 
served that  on  this  Bame  side  then  was  a  profuse  perspiration  when- 
ever he  exercised  physically,  and,  above  all,  when  he  drank. 

Dr.  Fleischnian,'  of  Vienna,  has  called  attention  to  like  facts,  in  a 
work  on  chronic  pneumonia  of  the  apex  of  the  lung  in  infants.     Be  has 

shown  that  in  such  cases  there  are  vascular  troubles  limited  to  one  side 
of  the  face  or  head,  and  transient  unilateral  erythema,  with  elevation 
of  the  local  temperature. 


CHAPTER   IV. 

PATHOLOGY  OF  THE  ABDOMINAL   SYMPATHETh: 

Tin:  greal  sympathetic  contributes  to  form,  with  the  vagus,  the 
several  plexuses  which  preside  over  the  function  of  innervation  of  the 
organs  contained  in  the  abdominal  cavity.  The  disorders  which  have 
their  scat  in  these  plexuses  arc  manifested  by  painful  sensations,  by 
motor  troubles,  by  exaggerated  or  insufficient  movements  of  the  con- 
tractile tissues  which   enter  into  the  constitution  of  the  abdominal 

organs,  and  by  circulatory  and  secretory  tl'Oubl 

In  the  affection  known  as  cramp  of  the  stomach  (gastralgia),  there 

veritable  contraction  of  the  walls  of  this  organ,  which  produces 

compression  of  the  terminal  extremities  of  the  nerves  of  the  stomachal 

pleXUS   and  violent    pain.      The    pain    i-,  hence,  only   a    consequence   ol 

the  motor  trouble.     However,  for  M.  See  the  gastric  pain  is  generally 
due,  not   to  a  contraction,  bul  to  a  distention  <>t"  the  stomach  !> 
and  the  consequent  stretching  of  the  nerves  resulting  therefrom. 

The  centres  which  regulate  the  secretory  function  of  the  stomach 
appear  to  be  situate. 1  in  the  walls  ,>t'  this  organ.  In  fact,  the  division 
of  the  pneumoga8tric  nerves,  as  well  as  the  destruction  of  the  plexus 
of  Auerbaoh  and  of  Meissner  with  ammonia  (Schiff),  has  no  influence 
,.vcr  digestion,  and  consequently  over  the  secretion  of  gastric  juioe 
Lamaensftj  bas  established  this  fact  in  animals,  from  which  he  had 

1  M  80,  L8Y6. 

50 


86G  DISEASES   OF   THE   SYMPATHETIC   NERVOUS   SYSTEM. 

extirpated  the  cceliac  plexus.  We  must,  therefore,  admit  an  autonomy 
of  the  gastric  vaso-motors,  similar  to  that  of  the  autochthonous  ganglia 
of  the  heart  and  intestines.  It  is  evidently  by  the  intermediation  of 
these  inter-parietal  plexuses  that  troubles  of  digestion  of  a  reflex  char- 
acter are  produced — for  example,  the  sudden  arrest  of  digestion  through 
the  influence  of  a  violent  emotion.  We  have  in  colic  another  func- 
tional trouble  of  the  abdominal  plexuses,  one  which  is,  in  reality,  a  neu- 
ralgia of  the  cceliac  plexus.  Lead-colic  is,  in  some  respects,  the  type 
of  this  variety  of  neuralgia.  Recently  Harnack  has  published  the  re- 
sults of  his  experimental  researches  on  the  physiological  action  of  lead, 
from  which  it  appears,  in  addition  to  other  facts,  that  the  metal  excites 
the  autonomous  ganglia  situated  in  the  walls  of  the  intestines.  In  man, 
this  excitation  is  especially  manifested  by  a  generalized  contraction  of 
the  intestinal  canal,  which  explains  the  obstinate  constipation  and 
colics  which  are  such  constant  symptoms  of  chronic  saturnine  intoxica- 
tion. In  animals,  however,  this  intoxication  occasions,  on  the  contrary, 
profuse  diarrhoea,  for  the  reason  that  lead,  by  exciting  the  autonomous 
ganglia  of  the  intestines,  produces  an  exaggeration  of  the  peristaltic 
movements  of  these  organs. 

It  is  also  to  an  excitation  of  the  nervous  plexuses  which  ramify  in 
the  walls  of  the  excretory  canals  of  the  liver  that  are  to  be  attributed 
the  painful  paroxysms  known  as  hepatic  colic.  Here  the  agent  of  ex- 
citation is  a  biliary  calculus,  plugging  up  the  choledic  or  cystic  duct, 
and  which,  by  reflex  action,  causes  the  contraction  of  the  walls  of  this 
canal.  A  strong  compression  of  the  nervous  plexuses  which  send 
numerous  branches  to  the  walls  of  the  excretory  ducts  of  the  bile  is 
thus  produced.  Accessions  of  nephritic  colic  are  developed  by  an 
identical  mechanism.  And  there  is  also  a  vesical  neuralgia,  character- 
ized, at  the  same  time,  by  pains  and  strangury,  this  last  being  the 
result  of  reflex  spasm  of  the  bladder,  which  is  due  to  the  pain  seated 
in  the  walls  of  this  organ. 

The  experiments  instituted  by  Rochefontaine  demonstrate  that,  if, 
in  an  animal,  we  tie  at  the  same  time  the  splenic  artery  and  the  nerves 
of  the  splenic  plexus,  the  spleen  becomes  congested,  while,  on  the 
contrary,  it  would  seem  as  if  the  vessels  should  empty  themselves  of 
their  contents.  To  explain  this  apparently  paradoxical  congestion,  it 
is  said  that  there  is  produced  a  true  aspiration  of  blood  to  the  splenic- 
veins,  by  reason  of  the  paralytic  relaxation  of  the  non-striated  fibres 
of  the  spleen,  caused  by  the  ligation  of  the  nerves  distributed  to  that 
organ.  However  correct  this  interpretation  may  be,  the  experiment 
of  Rochefontaine  may,  in  a  certain  way,  explain  the  development  of 
splenic  congestion  in  adynamic  fevers,  which  are  characterized  in  gen- 
eral by  a  marked  atony  of  the  nervous  system,  and  in  particular  of 
the  splanchnic  nerves. 

The  greater  number  of  the  congestive  phenomena,  which  have  the 


PATHOLOGY   OF   TOE   ABDOMINAL   SYMPATHETIC.  867 

litems  as  their  situation,  take  their  point  of  departure  in  an  irritation 
of  the  nervous  ramifications  which  the  genital  plexus  sends  to  the 
womb  and  its  anexse.     It  is  the  fact,  also,  as  regards  the  more  or 
painful  contractions  of  which   this  organ  is  the  seat,  either  in   the 
pregnant  or  non-pregnant  condition. 

Finally,  the  abdominal  sympathetic,  which,  in  the  physiological 
state,  gives  an  absolutely  unconscious  sensibility  to  the  viscera,  be- 
comes the  seat  of  extremely  violent  pains  when  it  is  deranged  in  its 
functions.  These  pains  arc  especially  apt  to  occur  when  the  terminal 
ramifications  of  the  visceral  plexuses  are  compressed,  either  by  the 
contraction  or  distention  of  the  Avails  of  a  hollow  organ,  or  by  a  wound 
or  injury.  Every  one  can  recall  in  his  own  experience  the  intense 
pain  caused  by  a  blow  on  the  epigastrium  or  on  the  testicles.  These 
viscera]  plexuses  are,  besides,  the  point  of  departure  for  reflex  phenom- 
ena, originating  either  at  the  places  injured  or  at  a  distance,  A  painful 
sensation  starting  from  the  testicle  leads,  at  first,  to  a  contraction  of 
the  muscular  tissue  of  the  Bcrotum,  with  retraction  of  the  testicles. 
When  this  pain  reaches  a  sufficient  degree  of  intensity,  the  walls  of  the 
abdomen,  and  of  the  several  hollow  viscera  contained  in  the  abdominal 
cavity,  enter  also  into  contraction.  There  may  even,  in  certain  c 
be  developed  general  convulsions,  with* or  without  lipothymia,  the  re- 
sult, doubtless,  of  the  reflex  contraction  of  the  vessels  of  the  nervous 
centres,  ami  of  the  olighemia  resulting  therefrom.  The  painful  irrita- 
tions transmitted  to  the  terminal  ramifications  of  the  splanchnic  nerves 
cause  also  contractions  of  the  abdominal  vessels.  Soon,  however, 
tlics,.  relax,  and  then  there  i-  a  stagnation  of  blood  in  the  abdominal 
sis,  through  the  formation  of  a  true  depol  capable  of  holding  the 
whole  of  the  blood  ill  motion,  when  their  paralytic  relaxation  pa 
Certain  limits.     Thus  are  explained  the  paleness  <>f  the  lace,  ami  of  the 

-kin  generally,  the  cyanosis,  the  coldness  of  the  extremities,  the  phe- 
nomena of  cerebro-spinal  anemia,  and  the  smallnesa  and  rapidity  of  the 
pulse,  thai  are  observed  in  all  cases  of  peril al  irritation,  and  also  in 

thecoma    ami    stupor  which    ensue   on    severe  WOUnds    and    injuries — a 

state  designated,  by  English  and  American  Burgeons, shock.  Goetzhas 
realized  the  conditions  under  the  influence  of  which  this  state  is 
developed,  in  his  well-known  experiment,  which  consists  in  Btriking 
the  belly  of  a  frog  against  the  edge  of  a  table.  He  has  seen  the  enor- 
mous development  of  tin  abdominal  vessels  and  the  ischemia  of  other 

ions  which    at    once   ensue,  ami   which   entirely  explain    the    morbid 

phenomena  observed  in  the  similar  instances  to  which  we  have  called 

attention. 


SECTION   VL 

CERTAIN   OBSCURE   DISEASES   OF   THE 
l^ERYOTTS   SYSTEM. 


CHAPTER   I. 

ACUTE  ASCENDING  PARALYSIS  {LANDRY'S  PARALYSIS). 

In  the  year  1859  Landry  described  a  form  of  paralysis  which  be- 
gan in  the  lower  extremities  and  rapidly  extended  upward,  involved 
successively  the  muscles  of  the  upper  extremities,  of  the  trunk,  and 
finally  of  respiration.  The  course  of  the  disease  lasted  but  a  few  days 
and  terminated  in  death.  No  lesion,  which  could  in  any  manner  be 
related  to  the  symptoms,  was  discovered.  Since  then  other  cases  simi- 
lar in  character  to  Landry's  have  been  reported  from  time  to  time. 
In  some  of  these,  palpable  lesions  were  observed,  in  others  nothing 
was  discovered. 

Westphal,1  in  his  exhaustive  article  on  this  subject,  showed  that 
those  cases  in  which  anatomical  lesions  were  found  were  cases  of  mye- 
litis and  of  meningeal  haemorrhage,  and  that  the  resulting  symptoms 
were  not  identical  with  those  of  Landry's  paralysis. 

Symptoms. — Premonitory  symptoms  may  or  may  not  be  observed. 
Sometimes  there  is  slight  fever,  or  there  may  be  a  feeling  of  weak- 
ness and  lassitude,  pains  in  various  parts  of  the  body,  and  numbness 
and  tingling  in  the  hands  and  feet.  Again  the  first  symptom  to 
attract  the  patient's  attention  will  be  a  decided  weakness,  usually  first 
manifested  in  the  feet  and  legs,  but  sometimes  beginning  in  the  hands. 
This  weakness  rapidly  increases  to  profound  paralysis.  The  upper 
extremities  are  affected  simultaneously  with  the  lower  extremities,  or 
else  very  soon  afterward.  The  muscles  of  the  trunk  are  next  in- 
volved. This  is  followed  by  shortened  and  labored  respiration,  and 
by  inability  to  defecate  on  account  of  the  paralysis  of  the  abdominal 
muscles.     As  the  paralysis  ascends  there  will  be  increased  difficulty  in 

1  Archiv  fur  Psychiatrie,  1876,  No.  6. 


ACUTE   ASCENDING   PARALYSIS.  869 

breathing,  which  is  often  paroxysmal  ;  indistinct  speech  and  inability 
to  swallow,  and  sometimes  by  double  facial  paralysis.  If  sensory 
symptoms  are  present  at  all,  and  they  usually  are  not,  there  will 
simply  be  a  slight  hyperalgesia  of  the  skin  or  a  slight  anaesthesia. 

The  muscles,  soon  after  paralysis  supervenes,  become  flabby  and 
flaccid,  but  they  continue  to  respond  to  both  forms  of  electrical  exci- 
tation. The  electrical  reactions  of  degeneration  are  not  exhibited. 
The  reflexes,  both  superficial  and  deep,  are  usually  lost. 

Causes. — Little  is  known  relative  to  the  etiology  of  this  remark- 
able disease.  Men  seem  more  liable  than  women  to  suffer  from  it. 
Cold,  syphilis,  typhoid  fever,  and  other  exhausting  diseases  have 
been  named  as  prominent  causes.  Westphal '  considers  that  some  toxic 
agent  acting  on  the  nerve  centres  through  the  blood  is  responsible  for 
the  peculiar  symptoms  exhibited.  I  am  strongly  inclined  to  accept 
tli is  view  of  the  case,  but  as  yet  the  question  has  not  been  satisfacto- 
rily determined. 

Diagnosis. — Acute  ascending  paralysis  may  be  confounded  with 
multiple  neuritis,  with  acute  anterior  poliomyelitis,  and  with  acute 
central  myelitis.  In  multiple  neuritis  there  is  severe  pain  and  tender- 
ness over  the  course  of  the  inflamed  nerves.  The  muscles  atrophy, 
and  electrical  degenerative  reactions  are  present.  Anterior  poliomye- 
litis may  likewise  be  differentiated  from  Landry's  paralysis  by  the 
rapid  muscular  atrophy  and  by  the  presence  of  the  electrical  reactions 
of  degeneration. 

In  acute  central  myelitis,  though  there  may  be  paralysis  of  motion, 
there  will  also  be  severe  sensory  symptoms  and  paralysi-  of  the  bladder 
and  of  the  rectum,  symptoms  which  are  not  observed  in  aeute  ascending 
paralysis.     There  are  no  other  affections  which  resemble  this  disease. 

Prognosis. — Acute  ascending  paralysis  is  usually  fatal.  Although 
instances  have  been  reported  In  which  recovery  has  taken  place,  there 
ie  reason  to  believe  that  all  of  them  were  not  cases  of  the  die 
under  consideration.  "Where  the  course  of  the  disease  is  rapid  and 
when  the  cranial  nerves  become  involved,  the  prognosis  is  hopeless. 
In  cases  in  which  the  disease  develops  slowly  and  dues  not  advance 

BO  as  to  implicate  the  nerve  centres  in  the  medulla,  the  prognosis  IS 
not  so  grave.  All  cases  must  be  regarded  as  serious  a-  long  as  the 
paralysis  is  ascending 

Morbid  Anatomy  and  Pathology. —In  typical  cases  of  acute  ascend- 
ing paralysis  no  anatomical  lesion  is  discovered.  In  some  instances 
changes  have  been  noted  in  the  spinal  cord,  in  the  meninges,  and  in  the 
medulla,  bat  these  cases,  as  Westphal  points  out,  are  not  clearly 
shown  to  have  Keen  instances  of  the  disease  under  consideration.  It  is 
probable,*  as  has  already  been  stated,  thai  Bome  toxic  agent  in  the 
blood,  acting  on  the  nerve  centres  in  the  spinal  oord  and  medulla,  is 

1   Op.  rit. 


870         CERTAIN    OBSCURE    DISEASES   OF   THE    NERVOUS   SYSTEM. 

responsible  for  this  condition.  This  theory  is  in  part  substantiated  by 
the  frequent  concurrence  of  inflammation  of  the  spleen  and  lymphatic 
glands  with  Landry's  paralysis,  these  symptoms  often  depending  upon 
a  toxic  condition  of  the  blood.  Nothing  definite,  however,  has  as  yet 
been  ascertained,  the  question  still  being  mainly  speculative. 

Treatment. — There  is  very  little  to  be  said  on  this  subject.  The 
internal  administration  of  ergot,  iodide  of  potassium,  and  mercury 
have  seemingly  been  followed  by  beneficial  results  in  some  cases  ;  in 
others  they  have  not  been  efficacious.  Counter-irritation  to  the  spine, 
such  as  blisters,  cold,  heat,  and  electricity,  have  been  recommended, 
but  it  can  not  be  claimed  that  much  benefit  has  been  derived  from 
their  use.  Tonics,  fresh  air,  passive  exercise,  and  moderate  active 
exercise,  if  it  be  possible,  should  exert  a  beneficial  influence. 


CHAPTER  II. 

MYXEDEMA. 

It  is  very  doubtful  whether  rnyxoedema  can  properly  be  regarded 
as  a  disease  of  the  nervous  system,  yet  there  are  so  many  nervous  and 
mental  symptoms  associated  with  it  that  a  brief  reference  to  it  will 
not  seem  out  of  place. 

The  first  account  of  the  remarkable  disease  now  known,  according 
to  the  suggestion  of  Dr.  Ord,1  as  rnyxoedema,  was  given  by  Sir  Will- 
iam Gull.2  He  did  not,  however,  attempt  any  very  complete  descrip- 
tion of  the  cases  that  had  come  under  his  observation,  nor  enter  at  any 
length  into  a  consideration  of  the  morbid  anatomy  and  pathology  of 
the  disease.  His  main  object  appeared  to  be  to  draw  attention  to  a 
well-marked  and  probably  not  uncommon  affection,  which  up  to  that 
time  had  not  been  differentiated. 

Subsequently  Dr.  Ord,  in  the  paper  cited,  made  a  very  thorough 
exposition  of  the  symptoms  and  morbid  anatomy  of  the  disease,  which 
apparently  leaves  little  to  be  discovered,  except  so  far  as  the  minute 
anatomy  of  the  nervous  structures  is  concerned.  So  positive  are  the 
data  furnished  by  the  writer,  that  it  seems  to  me  proper  to  consider 
the  affection  under  the  head  of  "  Diseases  of  the  Brain." 

Before  the  Clinical  Society,  October  10,  1879,  Dr.  Dyer  Duck- 
worth3 reported  cases  of  the  disease,  and  Dr.  Ord  read  another  papei 

1  "  On  Myxedema,  a  Term  proposed  to  be  applied  to  an  Essential  Condition  in  the 
Cretinoid  Affection  observed  in  Middle-aged  Women." — Medico-  Chirurgical  Transactions, 
vol.  lxi.,  p.  BY. 

2  "  On  a  Cretinoid  State  supervening  in  Adult  Life  in  Women." — Transactions  of  the 

d  Society  of  London,  vol.  vii.,  1874,  p.  180. 
;  Lancet,  vol.  ii.,  1879,  p.  577. 


MYXEDEMA.  871 

on  the  subject.  At  the  same  time,  Dr.  Sanders,  of  Edinburgh,  in  the 
debate  which  ensued,  mentioned  the  fact  that  several  cases  which  he 
now  recognized  to  be  instances  of  myxcedema,  had  come  under  his 
observation. 

Subsequently  Dr.  George  II.  Savage1  reported  cases  of  this  curious 
disorder,  and  gave  photographs  of  two  of  Dr.  Ord's  cases. 

In  this  country,  the  only  case  reported  is  one  which  occurred  in  my 
own  experience,  and  which,  with  an  account  of  what  had  been  previ- 
ously written  on  the  disorder,  formed  the  basis  of  a  memoir  which  I 
read  before  the  American  Neurological  Association,  June  16,  1880.8 

.since  that  time  two  cases  have  been  reported  by  Dr.  Thomas 
[ngli 

This,  I  believe,  embraces  all  the  literature  of  the  subject  up  to  the 
present  time. 

Symptoms. — Myxcedema  is  a  disease  which,  as  Dr.  Ord  has  shown, 
has  for  its  patho-anatomical  feature  the  deposit  of  a  mucoid  substance 
in  various  parts  of  the  body,  especially  in  the  skin  ;  or  a  degeneration 
and  proliferation  of  the  connective  tissue.  Probably  both  these  con- 
ditions coexist  in  some  tissues. 

As  a  consequence  of  this  state,  an  appearance  resembling  that  of 
anasarca  is  produced,  with  the  exec]  it  ion  that  the  pressure  of  the  finger 
on  the  part  does  not  leave  an  indentation.  The  tissue  is  resilient, 
and  not  boggy  like  that  into  which  water  is  infiltrated,  as  in  ordinary 
GBdema. 

The  face  has  very  much  the  appearance,  so  far  as  the  swelling  is 
concerned,  of  that  which  is  met  witli  in  cases  of  the  toxic  effect  of 
irsenic.  There  is  a  puffiness  of  the  eyelids,  the  li]>s  are  prominent,  the 
QOStrils  are  swollen,  and  the  cheeks  over  the  malar  bones  are  red  from 
capillary  congest  ion. 

Sir  William  Gull  was  much  impressed  with  the  "spade-like"  ap- 
pearance, as  he  called  it,  of  the  hands  and  fingers.  These  Latter  are 
"clubbed,"  as  they  so  frequently  are  in  those  cases  of  heart  disease  in 

which  there  IS  an  impediment  to  the  return  of  blood  to  the  light  Bide 
of  the  heart. 

The  temperature  of  the  body  is,  in  all  oases,  Ik  low  the  normal 
Btandard. 

Thus  far  all  the  instances  of  the  affection  reported  have  been  in 
adult  women,  unless  an  exception  «\  i^i  ^  a-  regards  one  in  a  man  oc- 
curring in  Dr.  Savage's  experience,  in  relation  to  which  there  is  some 
doubt  as  to  its  identity  with  myxcedema. 

The  cerebral  and  nervous  Bymptoms  appear  to  he  ven   decided. 

1  ./"  -I  iniirirv,   I  B80,  |>.    I  1  V. 

*"(>n   Myxoedema,  with  Special   Reference  i"  Its  Cerebral  Bymptoms. "— fif.   / 
Clinical  Record,  July,  1880,  p.  Vi       \ Iso    \  '  <  \      III.,  1881, 

ictt,  Beptember  26,  1880,  p.  L96, 


872         CERTAIN   OBSCURE   DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  intellect  is  notably  weakened,  and  replies  to  questions  are  given 
in  a  sluggish  and  inexact  way.  The  memory  is  imperfect,  and  the  pa- 
tient experiences  a  lack  of  confidence  in  herself  both  as  regards  men- 
tal and  physical  power.  The  special  senses  are  more  or  less  perverted, 
and  there  are  sometimes  hallucinations  or  delusions.  One  case  cited 
by  Dr.  Savage  "  was  distinctly  maniacal,  sleepless,  incoherent,  violent 
at  night."  The  most  ordinary  mental  condition  met  with  is,  however, 
a  lassitude  or  stupidity  resembling  the  state-generally  known  as  acute 
dementia. 

Such  are  the  most  marked  features  of  the  disease  as  described  by 
the  authorities  I  have  mentioned. 

Since  the  appearance  of  Sir  William  Gull's  and  Dr.  Ord's  papers, 
my  attention  has  been  directed  to  the  subject,  and  I  have  been  on  the 
look-out  for  cases  similar  to  those  described  by  these  gentlemen.  Two 
instances  onty  of  the  affection,  but  these  of  a  most  undoubted  charac- 
ter, have  as  yet  come  under  my  observation: 

Mrs.  H.  S.,  aged  forty-one,  consulted  me  first,  April  22,  1880.  I 
saw  her  again  April  29th,  and  again  May  6th.  Her  appearance  was 
that  of  a  person  suffering  from  general  oedema,  the  consequence  of 
heart  or  kidney  disease.  The  lower  eyelids  and  the  face  immediately 
below  them  were  turgid  ;  the  skin  over  the  forehead  was  rough  and 
swollen  in  spots  ;  the  nose  was  thick  ;  the  lips,  especially  the  lower  one, 
protruded  like  those  of  a  person  who  has  received  a  severe  blow  upon 
the  mouth  ;  and  the  skin  over  the  malar  bones  was  not  only  thickened, 
but  for  a  space  on  each  side  the  size  of  a  dollar  was  red  with  a  hectoid 
4ush. 

The  neck  was  also  greatly  swollen,  as  were  likewise  the  hands.  All 
the  fingers  were  "clubbed,"  but  there  was  no  incurvation  of  the 
nails. 

Extending  my  inspections,  I  found  that  the  whole  surface  of  the 
body  wras  similarly  affected.  At  no  place,  however,  could  pitting  be 
produced  by  pressure.  As  soon  as  the  end  of  the  finger  was  removed, 
the  depressed  surface  returned  to  its  ordinary  level. 

It  was  very  evident  that  this  was  a  case  of  myxcedema,  and 
the  continuance  of  my  inquiries  served  to  confirm  the  impression 
derived  from  a  simple  inspection  of  the  more  obvious  characteristics 
of  the  ease. 

The  general  sensibility  of  the  skin  was  markedly  diminished. 
Thus,  on  the  cheek,  the  two  points  of  the  sesthesiometer  could  barely 
be  distinguished  when  separated  to  the  extent  of  an  inch  and  a  half — 
three  times  more  than  the  normal  distance;  and  at  the  ends  of  the 
fingers,  where  they  should  have  both  been  felt  at  a  distance  apart  of 
the  twelfth  of  an  inch,  they  had  to  be  separated  five  twelfths  of  an 
inch  before  each  was  perceived.  A  like  condition  existed  in  the  skin 
of  the  trunk  and  lower  extremities. 


MYXEDEMA.  873 

At  an  early  period  she  bad  suffered  from  pains  in  various  regions 
of  the  head,  but  latterly  these  had  disappeared,  and  there  had  been  no 
similar  disturbances  of  sensibility  in  other  parts  of  the  body.  On  the 
contrary,  as  the  sesthesiometer  indicated,  sensibility  was  diminished. 
The  ends  of  the  fingers  felt  as  if  there  were  "  tight  thimbles  on  them," 
to  use  her  own  expression,  and  the  soles  of  her  feet  as  though  they 
were  padded  or  cushioned.  The  various  sensations  of  numbness  were 
present  more  or  less  in  the  face,  the  end  of  the  tongue,  and  the  arms 
and  legs. 

The  muscular  power  of  the  patient  appeared  to  be  decidedly  weaker 
than  was  normal.  The  gait  was  staggering,  the  feet  were  not  lifted 
clear  of  the  ground,  the  grasp  of  the  hands  was  feeble,  and  the  articula- 
tion was  sluggish  and  indistinct.  There  was  marked  difficulty  of  co- 
ordination b<-th  in  the  upper  and  lower  extremities.  Although  the 
patient  could  stand  with  the  eyes  shut,  she  walked  with  an  uncertain 
step  unless  her  eyes  were  directed  to  the  ground,  as  is  the  case  in  loco- 
motor ataxia.  She  could  not  put  the  finger  on  any  given  part  of  the 
face  unless  Bbe  had  her  vision  to  guide  her,  and  even  with  that  a- 
ance  she  did  not  readily  and  with  certainty  direct  the  movement-  of 
the  bands. 

The  other  special  senses  besides  the  touch,  which,  as  I  have  said, 
was  markedly  lessened  in  acuteness,  were  all  more  or  less  deranged. 
Ophthalmoscopic  examination  showed  the  existence  of  neuro-retinitis 
in  both  eyes  :  objects  Looked  blurred,  and  were  generally  apparently 
surrounded  with  a  halo.  Occasionally  she  had  had  momentary  double 
vision.  The  pupils  were  equal  in  size,  but  extremely  slow  to  respond 
to  an  increased  or  diminished  amount  of  light. 

The  hearing  was  diminished  in  acuteness.     With  the  left  ear  sh< 

could  not  hear  the  ticking  of  a  watch  at  a  greater  distance  than  twenty 
inches,  and    with    the  right    ear,   twenty-six    inches.      The  tuning-fork 

placed  "ii  the  forehead  was  heard,  bul  the  sound  was  not  intensified 
when  the  meatus  was  closed.  <>n  the  contrary,  it  seemed  to  be  less- 
ened. I  was,  therefore,  <>f  the  opinion  that  the  auditory  nerves  wen 
affected.     The  Eustachian  tubes  were  pervious. 

At  one  time  there  had  been  tinnitus,  bul   latterly  this  had  disap- 
ed.    There  was  no  impaction  of  cerumen,  and   tin-  drum-heads 
were  apparently  healthy. 

The  Benses  of  taste  and  smell  were  markedly  diminished  in  power, 
the  latter  being  almosl  entirely  abolished.  The  lining  membrane  of 
the  mouth  and  lane-  had  losl  a  great  deal  of  iis  normal  sensibility. 
Thus,  she  could  not,  by  the  taste  or  the  feeling,  from  the  contact  with 
the  tongue  and  mucous  membrane,  distinguish  a  clam  from  an  oyster, 

<u-  fish  from  roast   beef. 

The   menial    phenomena  were  not   LeBS  Strikingly  exhibited.      There 

wcit   frequent  hallucination-,  both  of  sight  and  hearing,  and  delusions 


874         CERTAIN   OBSCURE   DISEASES   OF   THE   NERVOUS  SYSTEM. 

that  attempts  were  being  made  by  certain  Frenchmen  she  spoke  of  to 
injure  her  with  oil  of  vitriol,  which,  she  declared,  they  put  into  the  bed 
in  which  she  slept  and  the  food  she  ate. 

There  was  manifest  deterioration  of  the  mental  power.  In  answer- 
ing the  simplest  question  she  looked  fixedly  at  the  interrogator  for  fully 
a  minute  before  speaking,  apparently  not  comprehending  its  purport, 
or  else  uncertain  what  reply  to  make.  Some  quite  simple  matters  she 
evidently  did  not  understand  at  all.  Thus  she  could  not  tell  me  how 
much  sixty  and  twenty-five  made  ;  and  when  I  asked  her  what  a  book 
was  made  of,  she  fixed  her  eyes  on  me  for  some  time  and  finally  said, 
"  Oh,  all  those  things,"  and  I  could  get  no  other  answer  out  of  her. 

Her  memory  was  equally  weakened.  She  required  much  prompt- 
ing before  she  could  tell  where  she  lived,  and  made  several  errors, 
which,  however,  she  corrected  herself,  in  giving  me  the  names  of  her 
children. 

Perhaps  her  memory  for  words  was  slightly  impaired,  but  certainly 
there  was  no  decided  aphasia.  She  could,  without  much  difficulty,  give 
the  names  of  all  articles  I  mentioned  to  her,  and  she  exhibited  no  other 
evidence  of  defective  articulation  than  that  due  to  paresis  of  the  tongue. 

She  slept  badly,  often  awoke  startled,  and  was  pacified  with  diffi- 
culty. 

The  hallucinations  to  which  I  have  referred  were  not  fixed.  Those 
of  hearing  consisted  of  human  voices  telling  her  how  the  "  French- 
men "  were  going  to  proceed  against  her,  and  of  the  "  Frenchmen " 
themselves  abusing  and  threatening  her.  Those  of  sight  were  of  en- 
tirely different  objects,  for,  strange  to  say,  she  never  saw  the  "  French- 
men." They  consisted  generally  of  apparitions  of  friends  who  had 
long  been  dead,  and  were  most  frequent  in  the  afternoon  and  evening. 

When  I  add  that  her  appetite  was  bad,  that  her  bowels  were  con- 
stipated, that  the  urine  contained  a  large  excess  of  urates,  without  other 
abnormality,  that  the  pulse  was  slow  and  feeble,  and  that  the  animal 
temperature  was,  in  the  axilla  and  under  the  tongue,  never  above  96° 
Fahr.,  and  often  half  a  degree  below  this,  I  have  given  as  full  an 
account  of  the  symptoms  as  is  necessary  for  a  full  understanding  of 
the  case. 

I  saw  nothing  more  of  this  patient  till  December  11,  1880,  when 
I  again  subjected  her  to  careful  examination.  I  then  ascertained  that 
the  temperature  in  the  axilla  and  under  the  tongue  had  fallen  to  94'8°, 
and  that  the  electric  contractility  of  the  muscles  to  both  the  galvanic 
and  faradaic  currents  was  markedly  lessened  in  all  parts  of  the  body. 
Generally,  the  disease  had  advanced.  The  strength  was  reduced,  the 
turgidity  of  the  face  and  limbs  had  increased,  and  the  sensibility  of 
the  skin  was  more  impaired  than  when  I  last  saAV  her.  In  addition,  the 
vision  and  hearing  had  become  so  much  affected  that  she  was  almost 
blind  and  deaf. 


MYXEDEMA. 


875 


As  regards  the  mental  symptoms,  there  had  been  no  advance,  and 
in  some  respects  a  Blight  degree  of  improvement  had  taken  place. 
Thus,  while  her  mind  appeared  to  be  fully  as  sluggish  as  when  I  first 
saw  her,  the  hallucinations  and  delusions  which  were  then  present  had 
disappeared,  and  no  others  had  taken  their  place.  In  fact,  she  had  for- 
gotten all  about  the  "  Frenchmen  "'  who  were  formerly  such  causes  of 
discomfort  to  her. 

Her  fingers  (Fig.  110)  were  more  enlarged  at  the  extremities  than 
they  were  when  she  was  last  under  my  charge,  and  I  discovered  that 

Fk;.  MO. 


her  toes  were  in  a  like  condition.  The  tongue,  which  at  former  exam- 
inations exhibited  do  evidence  of  departure  from  the  normal  appear- 
ance, was  now  decidedly  swollen,  and  the  speech  was  consequently 

more  labored  and  indistinct. 

The  urine  was  of  L018  specific  gravity,  and  was  free  from  albumen 
and  Bugar. 

Hut  while  writing  this  chapter  (January  7th)  a  second  case  has  come 
under  my  observation,  differing  in  no  essential  respeot,  except  a-  r<  gards 
the  stage  of  the  disease,  from  the  one  the  details  of  which  have  jusl 
been  given,  Of  this  instance  I  am  enabled  to  presenl  a  portrait  taken 
from  a  photograph  (Fig.  117).  The  patient,  a  female,  aged  thirty- 
three,  constitutes  what  I  should  consider  a  typical  case  of  myxoadema. 
With  her,  as  in  the  other  example,  the  mental  symptom-;  began  before 
anj  swelling  was  observed  in  the  lace  or  other  part  of  the  body,  and 
consisted  of  depression  of  spirits  amounting  almosl  to  melancholia 
Tin  re  arc  as  j  el  no  delusions. 

Tin    temperature  under  the   tongue   is  86*5  .     There  i<  a   good 
deal   of   irregular  action  of  the  heart,  and  there  is  very  persistent 

insomnia. 

The  swelling  is  more  noticeable  about   the  face  ami  neck  than  in 
other  parts  of   the  body.     The  fingers  arc,   however,   beginninj 


8TG 


CERTAIN    OBSCURE   DISEASES   OF   THE   NERVOUS   SYSTEM. 


show  the  "spade-like"  form,  and  the  appearance  of  oedema  is  notice- 
able about  the  arms  and  chest. 

The  further  consideration  of  this  case  is  deferred  till  I  have  had 
the  opportunity  of  studying  it  with  thoroughness. 


I<"iu.  117 


Causes. — Ssx  appears  to  be  a  strong  predisposing  cause,  for,  of  all 
the  cases  observed,  only  two  have  been  observed  in  males.  One  of 
these — and  it  is  somewhat  doubtful  if  this  was  a  true  instance — oc- 
curred in  the  experience  of  Dr.  Savage,  the  other  in  that  of  Dr.  Inglis. 
Age  is  also  a  determining  predisposing  cause,  for  all  the  cases  have 
been  observed  in  persons  who  have  reached  middle  life. 

Pregnancy  has  been  thought  to  exercise  a  predisposing  influence 
over  the  causation  of  myxcedema,  but,  as  I  think,  without  sufficient 
reason.  As  to  the  immediate  or  exciting  causes,  nothing  is  absolutely 
known. 

Diagnosis. — Myxcedema  is  not  a  disease  of  difficult  recognition. 
The  mental  phenomena  and  the  peculiar  swelling  of  the  body  will  of 
themselves  serve  to  diagnosticate  the  disease  from  any  other.  This 
oedema,  unlike  that  due  to  the  accumulation  of  serum  in  the  cellular 
tissue,  does  not  pit  upon  pressure,  but  is,  on  the  contrary,  resilient, 
just  as  is  a  rubber  ball  filled  with  air.  The  clinical  history  will  serve 
to  distinguish  the  swelling  of  the  face  from  the  like  condition  in- 
duced by  large  and  continued  doses  of  arsenic,  and  the  clubbed  fingers 
from   the  similar  formation   attendant  upon  those  cardiac  affections 


MYXEDEMA.  877 

which  interfere  with  the  return  of  the  blood  to  the  right  side  of  the 
heart. 

In  scleroderma  there  is  a  similar  swelling  of  parts  of  the  body,  due 
to  hypertrophy  of  the  skin,  but  in  this  affection  the  surface  is  hard, 
and  there  is  a  sensation  of  tightness  about  the  parts  involved  which  is 
not  present  in  myxcedeina.  Moreover,  there  is  no  permanent  reduc- 
tion of  the  temperature  of  the  body  in  scleroderma,  as  is  met  with  in 
myxedema,  and  there  are  no  mental  symptoms,  such  as  form  so  strong 
a  feature  of  the  latter  disease.  Scleroderma  is  a  disease  of  a  much 
younger  period  of  life  than  is  myxoedema,  most  of  the  eases  observed 
having  been  under  thirty-five  years  of  age. 

Notwithstanding,  however,  these  marked  points  of  difference,  it  is 
quite  probable  that  the  two  affections  have  been  confounded. 

Prognosis. — The  prognosis  is  bad.  Several  cases  have  terminated 
fatally,  and  in  no  one  has  there  been  any  amelioration  from  medicinal 
treatment.  Improvement  has  been  observed  in  a  few  cases  in  which 
operative  measures  have  been  resorted  to. 

Morbid  Anatomy  and  Pathology. — In  regard  to  the  connection  of 
the  phenomena  with  the  morbid  anatomical  condition  to  which  refer- 
ence has  been  made,  two  views  have  been  expressed. 

Dr.  Ord  regards  the  symptoms  as  being  directly  due  to  the  fact 
that  the  peripheral  terminations  of  the  nerves  are  so  surrounded  and 
compressed  by  the  mucoid  tissue  deposited  about  them  that  they  are 
prevented  receiving  impressions  in  their  full  force,  and  that,  hence, 
the  central  organs  of  the  nervous  system  act  less  energetically  than 
when  excitations  reach  them  in  full  force. 

The  other  view  is  that  the  symptoms  result  directly  from  the  in- 
ability  of  the  thyreoid  gland  to  perform  its  functions.  The  evidence 
bo  far  adduced  is  decidedly  favorable  to  the  latter  theory.  In  several 
instances  in  which  the  thyreoid  gland  has  been  removed  myxcedema 
has  supervened.      This  does  nut    Invariably  happen,  as   Billroth  has 

shown,  yet   it   is  undeniable   that   in  a  certain    proportion  of  08868    my\- 

. edema  follows  total  extirpation  of  the  thyreoid  gland,  while  it  is 
equally  certain  thai  the  symptoms  of  that  disease  do  ool  appear  if  one- 
third  of  the  -land  is  left  ///  situ.  The  fad  that  when  myxedema- 
tous symptoms  appear  tiny  can  often  be  relieved  by  transplanting 
healthy  thyreoid  glands  into  the  abdominal  cavity  of  the  affected  in- 
dividual   has   been    proved    by  actual    experiment.       Schiff    has   shown 

that  myxcBdema  can  be  everted  after  thyreoidectomy  if  other  thyreoid 
glands  are  attached  to  the  internal  abdominal  walls  or  to  the  mesen- 
tery ;  and  von  Easelberg's '  experiments  on  cats  confirm  SchifFa  results. 

Bicher'   relates   the   Case   of   a    woman    from  whom  the  entire   thyreoid 

gland  was  unintentionally  removed.    She  soon  developed  symptoms 

1  '*  I  .iter  Tetania  In  AnsohhiMe  an  Kropf-operatloneB,"  Wlen,  If 
3  "Sammlung  kliniaohe  V  •'"• 


878         CERTAIN   OBSCURE   DISEASES   OF   THE   NERVOUS   SYSTEM. 

of  myxcedema.  A  piece  of  thyreoid  gland  was  then  transplanted  into 
the  abdominal  cavity.  Marked  improvement  in  the  patient's  condition 
ensued  and  lasted  for  some  time,  but  eventually  the  symptoms  of 
myxcedema  reappeared,  necessitating  a  repetition  of  the  operation, 
which  was  again  followed  by  improvement.  Other  cases  are  not 
wanting  which  show  the  close  connection  between  total  extirpation  of 
the  thyreoid  gland  and  myxcedema,  but  it  is  perhaps  premature  in  the 
present  state  of  our  knowledge  to  accept  this  evidence  as  conclusive. 

Treatment. — Kbthing  in  the  way  of  internal  medication  appears  to 
have  been  of  any  material  service  in  the  treatment  of  myxcedema. 
Electricity,  tonics,  and  the  most  favorable  hygienic  surroundings  ap- 
parently make  no  impression  on  the  disease.  Following  the  investi- 
gations of  Schiff,  Bircher1  attempted  transplanting  thyreoid  glands 
into  the  abdominal  cavity  with  partial  success.  Koehn,  according  to 
Horslev,2  performed  a  similar  operation  in  1883,  but  the  graft  was 
absorbed,  and  the  patient  was,  therefore,  not  benefited.  Hearing  of 
Bircher's  case,  he  repeated  the  operation  on  five  different  cases.  In 
two  of  the  eases  the  transplanted  thyreoid  gland  was  stitched  to  the 
abdominal  walls  ;  in  three  other  cases  it  was  simply  placed  within  the 
abdominal  cavity.  One  of  the  patients  was  greatly  improved.  Other 
attempts  show  that,  though  the  operation  is  not  always  followed  by 
improvement  of  the  patient's  condition,  yet  it  affords  the  only  hope  of 
relief  from  an  otherwise  incurable  malady. 


CHAPTER   III. 

ACROMEGALY. 

Although  isolated  instances  of  enormous  hypertrophy  of  the  ex- 
tremities had  been  observed  for  a  number  of  years,  it  had  not  been 
considered  as  a  distinct  type  of  neurosis  until  Marie's  description  of 
the  disease  was  published.  Since  then  careful  investigation  has  thrown 
a  good  deal  of  light  upon  the  nature  of  this  obscure  affection. 

Symptoms. — Very  little  has  been  added  to  the  symptomatology  of 
the  disease  since  Marie's  very  complete  description.  The  first  evi- 
dences of  hypertrophy  usually  begin  in  early  life,  and  arc  gradual  in 
their  development.  The  hands,  feet,  and  head  slowly  enlarge  (ill  they 
are  considerably  out  of  proportion  to  the  rest  of  the  body.  In  the 
upper  extremities  the  hypertrophy  begins  in  the  lingers,  and  gradually 
advances  till  the  entire  hand  becomes  enormous.  The  form  of  the 
hand  is  rarely  out  of  proportion.  The  lines  in  the  fingers  and  hands 
are  deeply  marked,  and  are  bordered  by  massive  ridges  of  hypertro- 

1  Op.  cit.  2  British  Medical  Journal,  London,  1S90,  ii.,  786. 


ACROMEGALY. 

phied  skin.  The  nails  arc  flat,  wide,  and  short.  The  wrist  is  gener- 
ally slightly  increased  in  volume,  bul  much  less  bo  than  the  hand, 
while  the  forearm  and  arm  are  usually  unaltered.  The  feet  present 
the  same  general  characteristics  ;  they  become  huge  in  size,  flat,  and, 
like  the  hands,  are  surmounted  by  ridges  of  hypertrophied  skin.  Tin 
face  becomes  elongated,  principally  from  the  enlargement  of  the  in- 
ferior maxillary  bone.  The  other  bones  of  the  face  enlarge,  thus  dis- 
figuring  the  face  to  a  considerable  degree.  This  facia]  deformity  is 
enhanced  by  a  wonderful  development  of  the  nose,  which  increases  in 
all  dimensions,  and  frequently  attain-  an  enormous  si/.c.  Tin-  super- 
ciliary ridges  become  more  prominent,  and  the  lips,  ears,  and  eyelids 
are  thickened  and  massive.  The  cranium  often  participates  in  this 
gradual  growth,  and  when  it  does  so  it  usually  develops  equally  in 
all  dimensions.  The  muscles  are  usually  flabby,  ami  are  far  from  pow- 
erful, though  they  are  not  sufficiently  weakened  to  he  termed  paretic. 
Thomson,'  in  his  able  paper  on  this  subject,  shows  that  headache 

is  a  commou   symptom  ;   the   Slgbl    may  he  impaired,  and  at   times  lo-I 

altogether;  the  speech  is  sometimes  interfered  with;  there  is  often 

jsive  thirst  and  hunger;  and  the  disease  is  frequently  complic 
by  diabetes  mellitus.     In  women,  amenorrhea  is  often  observed. 

Prognosis. — There  is  little  to  he  said  on  this  subjeel  in  any  waj 
favorable  to  the  affected  individual.  No  instance  of  a  cure  ha-  as 
yet  been  reported.  The  patient  may  live  for  a  number  of  years,  bul 
gradually  weakens,  and  ( ither  dies  of  exhaustion  or  of  some  intercur- 
rent affection. 

Morbid  Anatomy  and  Pathology. — The  disease  i-  »'\  idently  a  tropho- 
neurosis of  obscure  origin.  The  enormous  increase  in  size  of  the  ex- 
tremities can  only  be  accounted  for  by  the  theory  of  an  abnormal  and 
•  stimulation  of  the  trophic  centres  supplying  the  hypertro- 
phied parts.  It  has  been  urged  that  atrophy  of  the  thyreoid  gland, 
which  has  been  sometimes  observed  to  occur  in  connection  with 
acromegaly,  mighl  he  the  pathological  foundation  for  the  disease,  hut, 
although  it  seems  probable  thai  the  thyreoid  gland  is  directly  con- 
cerned in  the  proper  nutrition  of  the  human  body,  il  ha-  not  been 
demonstrated  that  atrophy,  or  other  disease  of  the  thyreoid  glai 

il  a  constant  feature  of  acromegaly.     According  to  Th soi 

ever]  ccept   the  one  reported  by  Virchow,  the  pituitary  bod) 

has  been  found  to  be  greatly  enlarged  by  a  hyperplasia  of  it-  normal 
elements,  and  the  same  ohange  affects  the  ganglia  and  larger  net 
trunks  of  the  sympathetic  nervou  t.      Bul   in  Virchow's 

this  enlargement  of  the  pituitary  body  did  not  exist.     <  me  m  _r:it i \ « 
ii  as  this  sufficient  to  upset  a  theory,  no  matter  how 

'  Journal  ■■■ 


880         CERTAIN   OBSCURE   DISEASES   OF   THE   NERVOUS   SYSTEM. 

plausible  it  may  appear  at  first  sight.  It  is  quite  probable  that  the 
enlarged  pituitary  body  may  be  the  result  of  the  same  exaggerated 
hypertrophic  process  which  takes  place  simultaneously  in  other  parts 
of  the  body.  No  other  lesions  have  been  observed  which  throw  any 
light  upon  the  morbid  anatomy  of  this  strange  affection. 

Treatment — So  far  no  treatment  of  any  kind  has  been  efficacious 
in  arresting  the  progress  of  this  disease.  A  general  tonic  treatment, 
conjoined  with  proper  hygienic  surroundings,  may  serve,  for  a  time, 
to  improve  the  patient's  condition. 


CHAPTER  IV. 

THOMSEN'S  DISEASE  {MYOTONIA    CONGENITA). 

It  is  extremely  doubtful  whether  Thomsen's  disease  can  be  consid- 
ered in  any  respect  as  an  affection  of  the  nervous  system.  It  is  proba- 
bly primarily  a  muscular  disorder,  yet  there  is  sufficient  doubt  in  my 
mind  to  warrant  the  insertion  of  this  chapter  in  its  present  position 
until  the  precise  nature  of  the  pathological  conditions  which  produce 
this  disease  are  definitely  ascertained. 

Symptoms. — Though  Thomsen l  was  the  first  to  give  an  accurate 
description  of  this  peculiar  malady,  as  he  observed  it  in  his  own  case, 
and  in  his  son's,  it  was  not  until  Erb2  published  the  results  of  his 
study  of  over  twenty  cases  of  this  disease  that  much  light  was  shed 
upon  its  true  nature.  Thomsen's  disease,  or  myotonia  congenita,  de- 
pends upon  the  inability  of  the  affected  individual  to  relax  or  to  con- 
tract his  muscles  with  facility  after  a  period  of  rest.  This  stiffness 
and  rigidity  of  the  muscles  may  be  slight  at  times,  while  at  others 
there  may  be  complete  inhibition  of  movements.  Continuous  effort  to 
move  the  muscles  is  gradually  followed  by  dissolution  of  the  tension, 
until  finally  the  muscles  can  be  moved  freely  and  rapidly  in  all  direc- 
tions. After  a  short  period  of  rest  the  same  condition  of  stiffness  and 
immobility  is  found  to  exist  again.  An  individual  suffering  from 
Thomsen's  disease  who  attempts  to  arise  from  his  chair  finds  he  is 
totally  unable  to  do  so.  On  the  first  attempt  to  stand  erect,  the  mus- 
cles of  the  thighs  become  rigid  ;  gradually,  if  the  efforts  to  arise  are 
continued,  the  muscles  relax,  and  the  act  is  accomplished.  The  same 
condition  is  found  to  exist  in  the  upper  extremities.  Any  movement, 
from  a  state  of  repose,  is  executed  with  slowness  and  with  difficulty, 
and  sometimes  cannot  be  performed  at  all  until  after  several  moments 

1  Archiv  fur  Psych,  und  Nervenheilkwnde,  1876. 

2  "Die  Thomsensche  Krankheit,"  Leipzig,  1886. 


THOUSEX'S  DISEASE.  881 

of  continuous  effort.  After  the  muscles  have  once  been  induced  to 
act,  they  do  so  freely,  under  the  stimulation  of  the  will,  until  allowed 
to  rest,  when  they  are  again  found  tense  and  Btiff  on  the  next  attempt 
io  perform  a  voluntary  act. 

The  muscles  concerned  in  mastication,  and  also  the  muscles  of  the 
tongue  and  throat,  are  frequently  affected,  so  thai  chewing  the  food 
and  swallowing  it  are  attended  with  great  difficulty.  The  ocular  mus- 
cles are  seldom  involve  I. 

There  are  no  sensory  symptoms  of  any  importance,  or  whicl 
characteristic  of  the  disease. 

The  electrical  reactions,  as  described  by  Erb,1  are  very  peculiar. 
Thus,  he  says:  "If  a  large  electrode  is  placed  upon  the  nape  of  the 
neck,  and  a  smaller  electrode  in  the  palm  of  the  hand,  there  ensues, 
with  the  passage  of  a  galvanic  current  from  sixteen  or  eighteen  cells, 
a  steady  tonic  contraction  of  all  the  muscles  of  the  arm.  After  one 
or  two  changes  of  the  poles  a  Beries  of  wave-like  contractions  are  b< ■<  n. 
[f  the  cathode  is  in  the  hand,  these  contractions  begin  at  the  wrist- 
joint  and  pass  up  the  arm,  gradually  vanishing  as  they  approach  the 
ahoulder.  If  the  anode  is  in  the  hand,  the  waves  pass  downward. 
The  contractions  are  rhythmical,  and  follow  each  other  like  waves  pro- 
duced by  throwing  a  stone  into  water.  Sometimes  there  is  an  interval 
of  a  second  of  time  between  the  sequence  of  waves."  With  moderate 
faradaic  currents  normal  contractions  of  the  muscles  follow,  bul   if 

ng  currents  are  employed  the  muscles  contract  rigidly,  and  reman, 
contracted  for  some  time  after  the  electrodes  have  been  removed. 

Polar  degenerative  reactions,  though  they  have  been  at  tim< 
served,  are  nol  at  all  constant,  and  are  not  pathognomonic  of  the  dis- 
Reftex  excitability  is  very  much  exaggerated  in  the  affected 
muscles,  bul  the  contractions  which  ensue  when  a  muscle  is  struck  are 
slow,  and  continue  for  a  few  Becoi 

Causes.— Tin  re  is  unquestionably  a  strong  hereditary  influence  in 
the  majority  of  cases  thai  have  been  observed.  Isolated  instai 
however,  have  been  reported  in  which  do  hereditary  taint  could  '  i 
discovered.  The  disease  usually  shows  itself  in  early  childhood,  with- 
out depending  upon  any  exciting  cause,  or  at  least  upon  any  thai  can 
lie  detected. 

Diagnosis. — The  peculiarities  of  Thomson's  j  con- 

fusion with  any  other  affection  \ei\  improbable.  The  peculiar  i 
trical  reactions  which  have  never  been  observed  in  an]  other  disi 
and  the  rigidity  of  muscular  actions,  without   |  apammenl  of 

paralysis  or  atrophy,  will  be  sufficient  to  readily  determine  the  d 

Prognosis. — The  disease  b<  gins  In  childhood  and  lasts  as  |,  i 
the  individual  lives,  without  Bensibly  diminishing  the  length  of  life. 

1  "i 

67 


882         CERTAIN    OBSCURE    DISEASES   OF   THE   NERVOUS   SYSTEM. 

No  case  has  as  yet  been  cured,  and  the  probability  of  relief  being 
afforded  by  treatment  is  very  slight. 

Morbid  Anatomy  and  Pathology. — Erb  was  the  first  to  subject 
specimens  of  muscular  tissue,  taken  from  individuals  suffering  from 
Thomsen's  disease,  to  a  careful  microscopical  examination.  He  found 
the  muscular  fibres  hypertrophied  to  three  or  four  times  their  natural 
size,  the  nuclei  of  the  muscular  fibres  were  decidedly  augmented,  and 
the  intermuscular  connective  tissue  was  slightly  increased.  Jacoby1 
found  changes  similar  to  those  discovered  by  Erb.  The  muscular 
fibres  were  hypertrophied  to  double  their  normal  size,  and  were  rounded 
instead  of  polygonal.  The  nuclei  of  the  muscle-fibres  were  aug- 
mented, and  both  the  internal  and  the  external  perimysium  were  in- 
creased in  volume.  These  changes  may  be  primarily  myopathic,  and 
they  probably  are,  but  it  is  not  at  all  impossible  that  the  hypertrophy 
of  the  muscular  tissue  may  be  secondary  to  morbid  conditions  in  the 
central  nervous  system.  The  hypertrophy  of  the  bones  and  softer 
tissue,  as  they  occur  in  acromegaly,  are  probably  the  result  of  excessive 
stimulation  of  the  trophic  centres  which  are  in  direct  connection  with 
the  hypertrophied  parts.  In  Thomsen's  disease,  the  enormous  growth 
of  the  muscular  fibres,  and  of  their  connective  tissue,  may  depend 
upon  a  similar  abnormal  stimulation  of  trophic  centres  supplying  the 
hypertrophied  muscles.  As  I  have  previously  stated,  however,  the 
probability  of  Thomsen's  disease  being  primarily  of  myopathic  origin 
is  the  stronger,  but  as  yet  neither  theory  has  been  conclusively  proved. 

Treatment. — Nothing  within  the  range  of  medical  science  seems  to 
exert  any  beneficial  influence  upon  Thomsen's  disease.  Thomsen 
found  that  severe  muscular  exercise  was  of  service  to  him,  and  that 
when  it  was  followed  up  systematically  the  muscular  stiffness  and 
rigidity  was  at  its  minimum.  Other  sufferers  have  made  similar  ob- 
servations, but  no  instance  of  a  cure  has  resulted  from  this  method  of 
treatment. 


CHAPTER  V. 

RAYNAUD'S  DISEASE  (SYMMETRICAL   GANGRENE  OF  TflE  EXTREMITIES). 

Under  the  name  of  symmetrical  gangrene  of  the  extremities,  M. 
Maurice  Raynaud  described  for  the  first  time  in  1862  a  variety  of 
gangrene  which  since  then  has  been  given  a  place  in  systems  of 
nosology  as  a  distinct  and  morbid  entity.  It  presents  the  curious 
feature  of  being  developed  independently  of  any  lesion  of  the  cir- 
culatory apparatus. 

1  Journal  of  Nervous  and  Menial  Diseases,  18SG. 


RAYNAUD'S  DISEASE.  883 

Symptoms. — Generally  the  affection  is  observed  in  young  subjects, 
preferably  in  females,  and  with  those  who  possess  a  neurotic  diath 
Cold,  moral  emotions,  and  troubles  of  menstruation,  act  sometimes  a- 
causes. 

As  a  rule,  the  gangrene  attacks  symmetrically  the  lower  extremi- 
ties, more  rarely  the  upper  extremities  ;  sometimes,  also,  the  nose  and 
the  ears. 

In  the  beginning  the  patient  feels,  in  the  parts  which  are  about  to 
be  the  seat  of  the  gangrene,  a  sensation  of  tumefaction,  which  coin- 
cides with  the  paleness  of  the  skin  at  the  same  points.  At  other  times, 
the  skin  of  the  extremities  is  covered  with  bluish-colored  spots.  These 
are  the  indications  of  the  interference  with  the  circulation  which  pre- 
cedes the  development  of  the  gangrene.  This  local  ana?mia  may,  it  is 
true,  occur  without  there  being  Any  further  advance.  Then  the  parts 
primarily  exsanguined  become  the  seat  of  a  temporary  congestion, 
accompanied  with  more  or  less  severe  pains,  before  the  circulation 
again  becomes  regular.  The  condition,  in  fact,  resembles  that  induced 
by  the  local  application  of  cold.  This  local  anaemia  may  disappear 
and  reappear  many  times  ;  but,  when  it  is  the  prelude  to  the  mortifi- 
cation of  the  parts  affected,  the  skin  becomes  covered  with  phlyctenss, 
dry,  tense,  like  parchment,  and  assumes  tin-  black  coloration  peculiar 
to  sphacelated  tissues.  The  process  of  mortification  is  announced  by 
extremely  Bharp  pains,  which  the  patients  compare,  ordinarily,  to  the 
sensations  caused  by  burn-. 

Morbid  Anatomy  and  Pathology. — Inspection  of  the  limbs  aff< 
with  this  kind  of  gangrene  shows  the  absence  of  all  lesions  capable  <>f 
producing  obstruction  of  the  vessels  distributed  to  them.  There  is 
ueither  thrombosis,  embolism,  atheroma,  nor  any  alteration  whatever 
of  the  walls  of  the  Fessels.  Moreover,  M.  Maurice  Raynaud  hac 
called  attention  to  the  fact  of  the  persistence  of  the  pulse  in  the  ex- 
tremities, tin'  scat  of  the  affection  in  question. 

This  circumstance  indicates  clearly  that,  if  the  circulation  is  insufli- 

oient  for  the  proper  nutrition  of  the  ti-sucs,  it  is  not  entirely  abolished. 

To  explain  the  development  of  the  gangrene,  it  is  sufficient  to  sup- 
the  existence  of  a  durable  vascular  spasm  limited  to  the  affected 
pari  ;  and  this  is  what  M.  Maurice  Raynaud  has  done.  For  him,  the 
symmetrical  gangrene  of  the  extremities  and  the  local  anaemia  which 
i-ii>  immediate  cause  arc  the  consequences  of  a  spasm  of  the  small 

Is,  due  to  an  excitation  of   the  vaSO-motOr  nerves  which  innervate 

their  walls.     This  spasm  nuiy  1 f  a  reflex  order,  having  for  it  -  poinl 

of  depart  lire  a  peripheral  excitation  having  its  -eat  w  it  hi  n  the  extremi- 
ties threatened,  or  in  some  other  Organ      the  uterus  for  instance. 

This  excitation  will  be  reflected  by  the  vaso-motor  centre  situated 

in  the  hulk      Naturally,  the  produt  tion  of   this  va-culir  Bpasm  ai 

istence  under  the  ioflaenoe  of  an  occasional  oause  of  slight  impor* 


884         CERTAIN   OBSCURE   DISEASES   OF   TIIE   NERVOUS  SYSTEM. 

tance  suppose  that  the  reflex  centres  of  the  cord  are  in  a  morbidly 
exaggerated  state  of  excitability. 

M.  Vulpian,  while  admitting  the  theory  of  a  local  vascular  spasm 
as  the  cause  of  symmetrical  gangrene  of  the  extremities,  believes  that 
it  is  useless  to  allege  the  implication  of  the  vaso-motor  centres  in  the 
production  of  this  spasm.  This  eminent  physiologist  contends  that  the 
reflex  vascular  constriction  which  presides  over  the  development  of 
symmetrical  gangrene  of  the  extremities  is  produced  only  by  the  inter- 
mediation of  the  ganglia  situated  in  the  course  of  the  vaso-motor  fibres 
at  a  short  distance  from  their  terminations  in  the  vascular  walls.  The 
symmetrical  disposition  of  the  gangrene  is  more  in  accordance  with 
this  theory  than  with  that  which  makes  it  depend  upon  a  derangement 
of  the  central  innervation.  In  fact,  "  if  the  local  anaemia  of  the  ex- 
tremities is  so  often  symmetrical  in  the  affection  described  by  M.  Ray- 
naud, it  is  explained  by  the  fact  that  it  affects  subjects  in  whom  the 
local  predisposition  is  due  to  a  general  modification  of  the  economy, 
and  ought  to  be  nearly  equal  in  homologous  parts  of  the  two  sides  of 
the  body."1 

M.  Vulpian,  moreover,  contends  that,  if  gangrene  of  vaso-constric- 
tive  origin  is  always  symmetrical,  it  will  be  necessary  to  get  rid  of  some 
facts  which,  from  a  pathological  point  of  view,  naturally  are  embraced 
under  M.  Raynaud's  designation.  Thus,  in  this  connection,  he  recalls 
the  instance,  adduced  by  M.  Gubler,  of  a  gangrene  limited  to  one  of 
the  toes,  occurring  in  a  young' woman  in  whom  there  was  no  evidence 
of  a  closure  of  the  arteries  of  the  corresponding  limb.  It  would  evi- 
dently be  illogical  to  abstract  from  the  so-called  symmetrical  gangrene 
a  case  of  similar  pathogeny,  merely  because  the  gangrene  was  uni- 
lateral. 

In  a  more  recent  work,  M.  Raynaud  has  published  some  cases  of 
symmetrical  gangrene  of  the  extremities,  in  which  the  ophthalmoscope 
revealed  the  existence  of  a  constriction  in  the  central  artery  of  the 
retina.  Recently  Stevenson  •  reported  a  case  who  had  frequent  attacks 
of  partial  and  sometimes  of  complete  loss  of  vision.  The  ophthalmo- 
scope showed  that  the  central  arteries  of  the  retinas  were  constricted. 
This  is,  then,  the  basis  for  a  new  argument  in  support  of  the  vaso- 
motor theory  adopted  by  this  author.  As  a  practical  consequence  of 
the  vaso-constriction  theory,  M.  Raynaud  recommends  the  use  of  de- 
scending galvanic  currents  applied  to  the  vertebral  column  through- 
out its  length  These  currents  have  the  effect  of  weakening  the  ex- 
cito-motor  power  of  the  cord  and  bulb,  and  hence  of  combating  the 
vascular  spasm  of  central  origin,  which  is  the  point  of  departure  in 
symmetrical  gangrene  of  the  extremities. 

In  connection  with  the  affection  described  for  the  first  time  by  M. 

1  "  Lemons  sur  Fappareil  vaso-motcur,"  tome  ii.,  p.  620. 

2  Lancet,  London,  Nov.  1,  1890,  p.  917. 


RAYNAUD'S  DISEASE.  885 

Raynaud  under  the  name  of  symmetrical  gangrene  of  the  extremities, 
mention  must  be  made  of  the  condition  referred  to  by  M.  Vulpian1  as 
symmetrical  congestion  of  the  extremity  s. 

The  case  observed  was  that  of  a  patient  in  whom  regularly  every 
day  there  were  accessions  of  pain  and  heat  in  all  four  extremities,  espe- 
cially the  legs.  "  The  skin  became  red  and  very  hot,  the  arteries  of 
the  feet,  the  pulsations  of  which  could  scarcely  be  felt  in  the  intervals, 
during  the  paroxysms  beat  with  great  force,  and  appeared  to  be  dilated. 
There  was  at  the  same  time  a  very  painful  feeling  of  tension,  an  1 
walking,  by  aggravating  these  troubles,  became  impossible.  The  pa- 
tient only  found  relief  by  plunging  his  feet  and  the  lower  part  of  his 
legs  in  cold  water."  M.  Vulpian,  with  some  reserve,  is  nevertheless 
disposed  to  see  in  this  case  an  example  of  a  symmetrical  neurosis  of 
the  extremities,  determining  by  reflex  action  the  dilatation  of  the  ves- 
sels of  these  parts 

Treatment. — Nothing  in  the  way  of  treatment  has  yet  been  devised 
which  in  any  way  controls  the  manifestations  of  the  disease  except, 
perhaps,  the  continuous  galvanic  current.  Raynaud3  has  described 
which  were  relieved  in  this  manner.  The  positive  pole 
should  he  applied  at  the  cervical  region  while  the  negative  pole  should 
be  in  contact  with  the  hand.  A  moderate  but  continuous  current 
should  lie  allowed  to  flow  daily,  if  possible,  for  fifteen  or  twenty  min- 
utes at  a  time. 

1  Op.  cit.,  tome  ii.,  p.  623. 

2  Pub.  of  New  Sydenham  Soc,  exxi. 


SECTION   VII. 

TOXIC   DISEASES   OF  THE   NERYOUS 
SYSTEM. 


There  are  certain  substances  which,  when  taken  into  the  body 
gradually  and  for  a  long  time,  manifest  their  poisonous  influence  more 
especially  upon  the  nervous  system.  Among  these,  lead,  alcohol,  bro- 
mine, mercury,  and  arsenic,  may  be  particularly  mentioned.  Several  of 
these  substances  are  used  as  slow  poisons  with  criminal  intent,  others 
are  habitually  employed  by  many  persons  as  stimulants,  sedatives,  or 
cosmetics,  others  are  used  in  the  arts,  and  hence  enter  the  systems  of 
those  who  are  brought  in  contact  with  them,  and  some  are  prescribed  in 
such  doses  in  the  treatment  of  disease  as  to  produce  ujDon  the  patient 
their  characteristic  physiological  effects. 

It  seems  important  that  the  peculiar  phenomena  which  these  sub- 
stances are  capable  of  causing,  with  the  rationale  of  their  mode  of  ac- 
tion, and  the  treatment  best  adapted  to  obviate  their  deleterious  effects, 
should  receive  some  attention,  and  I  shall  therefore  devote  a  few  pages 
to  their  consideration. 


CHAPTER  I. 

PLUMBISM. 


Symptoms. — The  phenomena  manifested  in  the  nervous  system,  as 
consequences  of  lead-poisoning,  are  lead-encephalopathy,  paralysis, 
a  spasmodic  and  painful  affection  called  lead-colic,  a?icesthesia,  and  hy- 
peresthesia. 

a.  Lead- Encephalopathy. — The  symptoms  referable  to  the  brain, 
due  to  lead-poisoning,  may  be  slight  or  severe.     In  the  first  case  the 


PLTTMBISM.  ss; 

patient  suffers  from  headache,  vertigo,  and  various  other  abnormal  sen- 
sations, such  as  fullness,  and  constriction,  and  is  at  the  same  time  in- 
capable of  much  intellectual  exertion  without  suffering  an  increase  of 
his  physical  symptoms.  His  mind  is  irritable  and  depressed,  and  his 
sleep  is  usually  disturbed  with  unpleasant  dreams.  The  digestion  is 
generally  deranged,  and  the  whole  appearance  may  be  cachectic.  Tre- 
mor may  exist,  especially  in  the  hands.  It  is  generally  not  exten- 
sive, consisting  ordinarily  of  slight  tremulous  movements,  which,  though 
present  when  the  muscles  are  at  rest,  is  more  distinctly  manifested 
when  the  muscles  are  put  in  voluntary  action. 

This  condition  may  undergo  no  further  development,  but  it  is  often 
the  precursory  state  of  the  more  severe  form  of  the  affection. 

In  the  severe  form  the  symptoms  may  be  manifested  by  delirium, 
convulsions,  or  coma,  or  by  any  two  or  all  of  these  phenomena.  This 
last  was  the  case  in  a  patient,  a  master-plumber,  in  whose  case  I  was 
consulted  in  the  summer  of  18T3.  The  attack  began  with  acute  deliri- 
um, lasting  several  days,  and  then  alternating  with  paroxysms  of  con- 
vulsions. The  seizure  ended,  after  about  two  weeks,  with  profound 
coma  of  forty-eight  hours'  duration. 

In  the  delirious  form  the  patient  may  either  present  the  symptoms 
of  acute  mania  with  excitement,  or  there  may  be  a  melancholic  condi- 
tion present.  In  either  case  there  are  illusions,  hallucinations,  and 
.'illusions.  After  a  variable  period  a  remission  generally  takes  place, 
and  this  may  go  on  to  a  complete  disappearance  of  the  svmptoms,  or 
be  succeeded  by  a  renewed  exacerbation. 

In  the  convulsive  form,  the  paroxysms  may  or  not  be  marked  by  loss 
of  consciousness.  Tiny  may  be  limited  to  a  particular  part  of  the  body, 
as  the  face,  neck,  or  arms,  or  they  may  be  general.  They  may  present 
lomewhat  the  characteristics  of  tetanus  or  of  epilepsy,  or  of  botli  these 
diseases.  In  some  case3  the  seizures  are  not  distinguishable  From  idio- 
pathic epileptio  attacks;  the  patient  has  tonic  and  clonic  convulsions, 
(roths  at  the  mouth,  bites  the  tongue,  may  evacuate  bis  urine  or  fasces, 
and  passes  into  a  soporous  condition.  Or  there  may  be  repeated  at- 
tacks surr ling  each  other  with  such  rapidity  as  to  constitute  a  s/<t'its 

epUepticua. 

In  the  comatose  variety,  the  stupor  is  sometimes  developed  with 

i  suddenness,  but  is  uot  often  so  profound  as  to  prevent  occasional 

manifestations  of  partial  sensibility.     Thus,  if  the  patient  be  spoken  to 

in  a  loud  voice  lie  opens  his  eyes,  or  if  the  skin  he  pinched  he  withdraws 

I  he  part  or  contorts  the  countenance. 

The   pupils  are  generally  dilated  and  insensible  to  light,  and  the 

oheekfl    and    lips   are    puffed    out    in    expiration.       If,    in    eases    in   which 

these  symptoms  occur,  the  gums  he  examined,  a  blue  line  running 
along  their  margins  will  he  discovered.  Sometimes  the  whole  extenl  ^i 
the  gums  is  tinged,  hut  gen<  rally  the  discolored  portion  i-  the  edge  in 


888  TOXIC  DISEASES   OF   THE   NERVOUS  SYSTEM. 

contact  -with  the  teeth,  and  about  a  line  or  at  most  two  lines  in  width 
Besides  the  discoloration,  the  tissue  of  the  gums  becomes  soft  and 
spongy,  and  it  may  become  absorbed,  leaving  the  roots  of  the  teeth  ex- 
posed. All  these  changes  are  more  marked  in  the  lower  than  in  the 
upper  jaw. 

The  breath  is  usually  of  a  peculiar  odor,  and,  if  what  is  called  the 
lead-cachexia  be  present,  the  complexion  is  pale,  the  hair  lustreless  and 
dry,  and  the  body  emaciated.  It  not  unfrequently  happens  that  the 
individuals  who  suffer  from  lead-encephalopathy  have  also  been  the 
subjects  of  some  one  or  more  of  the  other  manifestations  of  lead-poi- 
soning. 

b.  Lead-Paralysis. — Symptoms. — Before  the  occurrence  of  paralysis, 
the  patient  has  probably  suffered  from  attacks  of  lead-colic,  or  some 
other  affection  due  to  lead-poisoning,  though  this  is  not  invariably  the 
case.  The  immediately  precursory  symptoms  connected  with  the  loss 
of  power  are  slight  numbness  and  tremors  in  the  muscles  of  the  upper 
extremities.  Occasionally,  the  muscles  of  the  trunk  and  lower  extremi- 
ties become  involved  in  the  trembling. 

Ere  long  the  patient  observes  that  he  has  difficulty  in  extending  the 
fingers  or  wrist,  and  that  there  is  a  general  loss  of  strength  in  one  or  both 
hands.  These  symptoms  go  on  increasing  in  severity,  and  eventually 
he  loses  the  power  to  raise  the  hand  or  fingers.  In  extreme  cases,  the 
ability  to  extend  the  forearm,  or  to  raise  the  arm  from  the  side,  is  lost 
through  the  paralysis  of  the  triceps  and  deltoid,  or,  as  in  a  case  before 
my  clinique,  in  January,  1876,  the  biceps  may  be  paralyzed.  Occa- 
sionally the  extensors  of  the  lower  extremity  are  involved  in  the 
paralysis. 

The  predominance  of  the  loss  of  power  in  the  extensors  has  led  to 
the  idea  that  they  alone  are  affected.  The  dropping  of  the  hand,  the 
flexion  of  the  forearm  on  the  arm,  the  hanging  of  the  arm  against  the 
side  of  the  body,  and,  when  the  lower  extremity  is  affected,  the  inabil- 
ity to  i*aise  the  toes  so  as  to  avoid  striking  them  against  the  ground  in 
walking,  all  give  countenance  to  this  supposition.  But  careful  obser- 
vation shows  that  the  difference  is  merely  one  of  degree,  and  that 
there  is  a  very  considerable  loss  of  power  in  the  flexor  muscles.  In- 
deed, of  many  cases  of  the  disease  that  I  have  observed  in  hospital 
and  private  practice,  I  have  never  seen  one  in  which  the  flexors  were 
not  implicated  with  the  extensors. 

Owing  to  the  disuse  of  the  muscles  and  to  their  want  of  proper  nu- 
trition, atrophy  takes  place,  and  this  is  frequently  exceedingly  well 
marked,  and,  from  the  disturbance  of  the  normal  equilibrium  between 
the  several  groups  of  muscles,  contractions  and  distortions  ensue.  The 
circulation  in  the  affected  limbs  becomes  languid  and  weak,  and  pain- 
ful swellings  result  in  consequence. 

It  is  generally  supposed  that  the  right  arm  is  more  apt  to  bo 


PLUMBISM.  s>«, 

affected  than  the  left ;  such,  however,  does  not  appear  to  be  the  c 
Thus,  Tanquerel  des  Planches,'  of  seventy-nine  cases  in  which  the 
tipper  extremities  were  the  Beat  of  the  paralysis,  found  both  affected  in 
fifty-one,  the  left  twenty-three  times,  and  the  right  twenty-four.  <  M* 
thirty-two  cases  of  lead-paralysis  occurring  in  my  own  practice,  tin- 
upper  extremities  were  affected  in  all  ;  in  twenty-seven  both  limbs 
were  the  seat  ;  and,  of  the  remaining  five,  three  were  in  the  left,  and 
two  in  the  right.  The  left  upper  extremity  was  therefore  affected 
thirty  times,  and  the  right  twenty-nine. 

In  some  cases,  the  muscles  of  respiration  become  very  Beriously 
paralyzed  through  the  influence  of  lead,  and  death  then  bood  takes 
place.  In  two  of  my  cases  there  was  aphonia,  and  in  several  the  voice 
was  materially  weakened.  Cases  of  hemiplegia,  the  result  of  lead- 
poisoning,  have  been  observed  by  Stoll,  Andral,  and  Tanquerel  des 
Planches. 

The  elect  ric  sensibility  and  contractility  are  always  greatly  reduced 
in  all  cases  of  lead-paralysis.  In  the  majority  of  cases,  no  faradaic  cur- 
rent, which  it  is  Bafe  to  employ,  will  produce  contractions,  and  strong 
galvanic  currents  are  necessary.  The  polar  reactions  of  degeneration 
(page  28)  are  usually  well  marked.  The  cutaneous  Bensibility  is 
rarely  impaired. 

The  saturnine  cachexia  is  almost  always  present,  and  the  blue  line 
on  the  gums  can  readily  be  distinguished. 

c.  Lead-Colic. — This  is  probably  the  most  common  affection  caused 
by  the  toxic  influence  of  lead,  and  has  been  recognized  from  a  very 
early  period. 

Symptoms. — Lead-colic  is  particularly  characterized  by  the  presence 

of  pain,  the  apparent  seat  of  which  is  at  or  near  the  umbilicus,  although 

it  may  exist  at  the  epigastrium,  the  hypogastrium,  or  some  other  part 
of  the  abdomen. 

Tin-  character  of  the  pain  is  somewhat  peculiar,  being  a  twisting 

ition  of  great  agony,  which  appears  to  revolve  around  the  umbili- 

In  some  oases  the  distress  of  the  patient  is  extreme,  and  he  gives 

utterance  to  loud  cries  of  anguish,  and  tosses  himself  about  with  the 

utmost  violence.     Nausea  and  vomiting  are  generally  present,  and  the 

bowels  arc  almost  invariably  constipated. 

The  respiration  is  ordinarily  hurried  and  irregular,  bul  the  pulse, 
notwithstanding  the  physical  and  mental  excitement,  remains  of  its 
normal  force,  frequency,  and  rhythm,  sometimes  becoming  markedly 
slower  during  the  heigh"  of  ■  paroxysm. 

The   abdomen    is   usually   hard   and   r«  t  v.  My   during  the 

height  of  a  paroxj 

i  I     isionally  the  abdomen  is  painful  to  the  touoh,  and  the  suffering 
\ ate. I  by  ■  ire,  bul  as  a  rule  this  is  not  the 

1  '•  I  plomb,"  P  tODM  ii..  p 


890  TOXIC   DISEASES   OF   TIIE   NERVOUS  SYSTEM. 

On  the  contrary,  the  pain,  so  far  from  being  increased  by  pressure,  is 
greatly  relieved  by  it,  especially  if  the  force  be  exerted  in  a  uniform 
and  gradual  manner.  Patients  often  discover  this  fact  for  themselves^ 
and  will  lie  on  the  belly  or  press  it  with  their  hands,  or  beg  that  others 
will  do  so. 

The  duration  of  a  paroxysm  is  variable.  It  may  last  only  a  few 
minutes,  or  may  be  prolonged  for  an  hour  or  more.  A  period  of  com- 
parative calm  then  ensues,  during  which  the  exhausted  patient  may 
sleep  a  little,  but  his  slumber  is  soon  disturbed  by  another  seizure,  and 
this  sequence  may  continue  for  several  days.  Paroxysms  are  more  com- 
mon and  more  severe  during  the  night  than  the  day,  and  sometimes  the 
relation  is  observed  with  sidereal  punctuality. 

In  consequence  of  the  treatment  adopted,  or  spontaneously,  the 
series  of  attacks  is  broken,  and  the  patient,  for  the  time  at  least,  re- 
covers his  ordinary  state  of  health.  It  is  exceedingly  rare  that  death 
ensues  from  simple,  uncomplicated  lead-colic. 

d.  Lead- Anaesthesia. — Anaesthesia,  as  a  condition  due  to  the  toxic 
influence  of  lead,  may  exist  without  complication  with  other  manifes- 
tations, although  such  an  event  is  not  common.  In  the  majority  of 
cases  it  is  the  optic  nerve  which  is  affected,  and  as  a  consequence  more 
or  less  complete  blindness  is  produced.  Some  of  the  cases  formerly 
reported  were  probably,  as  Stellwag l  observes,  simply  instances  of 
ciliary  paralysis,  but  this  author  admits  the  existence  of  an  organic 
affection  of  the  nerve,  terminating  in  atrophy,  and  recognizable  by  the 
ophthalmoscope. 

Again,  the  anaesthesia  may  affect  the  skin  of  the  trunk  or  extremi- 
ties, or  the  muscles  of  these  parts.  It  is  developed  generally  with  great 
rapidity,  reaching  its  height  in  a  few  hours. 

e.  Lead-Hyperaisthesla. — The  pains  in  the  limbs  and  trunk  are 
among  the  most  common  of  the  phenomena  of  lead-poisoning.  The 
lower  extremities  are  generally  their  seat,  and  by  preference  the  flex- 
ures of  the  joints.  Thus  the  groin  and  the  popliteal  space  are  favorite 
situations  in  the  lower  limbs;  the  axilla  and  bend  of  the  elbow  in  the 
upper  extremities.  The  back  and  thorax  are  also  often  affected,  and 
sometimes  the  scalp,  face,  and  neck. 

The  pains  may  be  either  of  a  dull  aching  character,  acute,  like  the 
sensation  from  the  thrust  of  a  sharp  instrument,  or  hot,  as  if  a  coal 
of  lire  were  in  contact  with  the  part.  They  occur  in  paroxysms,  and 
are  apparently  excited  by  cold,  movements,  or  emotionul  disturb- 
ance. Occasionally  there  are  spasmodic  contractions  of  the  muscles 
of  the  painful  part,  either  en  masse,  singly,  or  in  the  form  of  fibrillary 
contractions. 

Like   the    pains   of    lead-colic,   they   are    generally   relieved    by 

1  "  A  Treatise  on  the  Diseases  of  the  Eye,"  Ilackley  and  Roosa's  translation,  New 
York,  1868,  p.  6G8. 


PLTJMBISM.  891 

steady  and  gradual  pressure,  but  occasionally  this  is  not  the  case, 
any  kind  of  touch,  light  or  heavy,  causing  an  aggravation  in  their 
intensity. 

There  is  no  increased  heat  of  the  painful  region,  no  redness  or  swell- 
ing, and  the  pulse  is  generally  normal. 

In  some  cases  the  pains  appear  to  be  seated  in  the  bones  ;  usually, 
however,  the  skin  and  muscles  seem  to  be  their  situation. 

Causes. — The  fact  that  such  affections  as  those  mentioned  follow  the 
introduction  of  lead  into  the  system  admits  of  no  doubt.  This  intro- 
duction may  take  place  through  the  stomach,  the  air-passages,  or  the 
skin.  The  two  latter  are  the  more  common  channels  for  contamina- 
tion. 

They  are,  of  course,  more  frequently  encountered  among  those  who 
work  in  lead,  such  as  lead-founders  and  smelters,  the  makers  of  white 
and  red  lead,  painters,  plumbers,  printers,  etc.;  although  they  may  occur 
among  those  who  are  only  temporarily  or  accidentally  exposed  to  the 
toxic  influence.  Thus,  they  may  be  caused  by  drinking  water  which  has 
passed  through  lead  pipes,  or  been  kept  in  lead  vessels,  or  by  using  to- 
bacco which  has  been  wrapped  in  lead-foil.  Two  cases  in  which  paral- 
ysis was  produced  by  the  latter  cause  have  happened  in  my  experience,1 
and  it  is  so  common  a  cause  that,  in  France,  Belgium,  and  Prussia, 
strong  laws  have  been  passed  against  packing  tobacco  in  lead.  The 
use  of  hair-dyes  containing  lead  is,  I  think,  quite  a  common  cause  of 
plumbism.  Three  cases  of  paralysis  and  two  of  anaesthesia,  in  which 
this  was  the  cause,  have  come  under  my  observation,  and  I  am  inclined 
to  think  that  a  case  in  which  there  were  vertigo,  slight  delirium,  and 
one  epileptic  convulsion,  owed  its  origination  to  the  application  of  had 
to  the  hair. 

The  employment  of  powders  and  enamels  to  the  face  is  a  not  infre- 
quent cause  of  plumbism  in  women,  as  most  of  those  substances  called 
cosmetics  contain  lead.     Three  cases  of  paralysis  and  one  of  pains  in 
the  body  and  limbs,  caused  by  lead  applied  to  the  face,  neck,  and  arms 
bare  occurred  in  my  experience. 

The  use  of  plasters  and  lotions  containing  lead  has  also  l><  en  known 
.  ••  rise  to  plumbism. 

The  majority  of  oases,  however,  occur  in  this  country  in  painti  rs, 
probably  for  the  reason  that  workers  in  white  and  red  lead,  though 
more  exposed,  are  aware  of  their  danger,  and  take  effeotua]  measures 
to  prevent  absorption. 

Though  ill"  carbonate  is  probably  the  most  actively  poisonous  prep- 
aration of  lead,  it  is  very  certain  that  all  tonus — qoI  even  exoepting 
the  sulphate — are  capable  of  producing  the  characteristic  phenomena 
of  plumbism. 

'  Bm  in'  R  lationfl  i" 


892  TOXIC   DISEASES   OF   THE   NERVOUS   SYSTEM. 

Diagnosis. — The  history  of  the  case,  including  a  knowledge  of  the 
occupation  of  the  patient,  or  of  his  exposure  to  the  action  of  lead,  will 
generally  prevent  error  of  diagnosis  in  regard  to  any  of  the  manifes- 
tations of  plumbism.  The  presence  of  the  peculiar  cachexia  and  the 
existence  of  the  blue  line  around  the  gums  will  tend  still  further  to  ren- 
der the  diagnosis  accurate. 

Again,  it  has  been  ascertained,  by  the  researches  of  Melsens,  that  the 
iodide  of  potassium  has  the  faculty,  when  taken  into  the  system,  of  de- 
composing the  albuminates  with  which  the  lead  is  united,  and  of  setting 
this  substance  free.  It,  then,  at  once  appears  in  the  urine,  and  can  be 
detected  by  examination  with  sulphuretted  hydrogen.  A  ready  meth- 
od is  that  proposed  by  Reeves.  A  piece  of  sulphide  of  potassium  is 
inclosed  in  a  piece  of  thin  white  linen,  and  suspended  in  a  vessel  con- 
taining the  urine  suspected  to  contain  the  lead  set  free  by  the  previous 
administration  of  the  iodide  of  potassium.  It  is  left  there  for  five  or 
six  minutes.  If  the  urine  contains  any  salt  of  lead,  it  is  decomposed, 
and  the  metal  is  deposited  on  the  linen  in  the  form  of  the  sulphuret, 
staining  it  of  a  dark,  almost  black,  color. 

As  regards  the  several  affections  separately,  it  is  to  be  remarked 
that  most  difficulty  will  be  experienced  relatively  to  the  encephalopathy 
produced  by  lead.  Jaccoud a  has  pointed  out  that  in  the  condition  of 
the  bodily  temperature  we  have  an  additional  point  toward  discrimi- 
nating between  acute  cerebro-spinal  meningitis  and  the  affection  under 
notice.  In  the  former  the  temperature  rises  to  104°  Fahr.,  or  even 
higher,  while  in  the  latter  there  is  no  augmentation,  or  at  least  a  very 
slight  rise. 

In  lead-paralysis  the  fact  that  the  loss  of  power  mainly  affects  the 
extensors,  especially  those  of  the  hand,  together  with  the  antecedents 
of  the  patient,  and  the  presence  of  other  evidence  of  plumbism,  will 
generally  suffice  to  render  the  diagnosis  certain.  I  have  recently,  how- 
ever, had  a  case  at  my  clinique  at  the  University  Medical  College,  in 
which  there  was  some  doubt.  The  patient  had  paralysis  of  the  exten- 
sors of  both  wrists.  Several  weeks  before  its  appearance  he  had  broken 
his  ankle,  and  had  been  obliged  to  walk  on  crutches.  There  was,  there- 
fore, a  question  a3  to  whether  the  case  was  one  of  "  crutch-paralysis," 
from  pressure,  or  of  lead-paralysis.  The  man  was  a  laborer,  and  had 
never,  to  his  knowledge,  been  exposed  to  lead  in  any  way.  But  the 
facts  that  there  was  no  anaesthesia,  that  the  paralysis  was  greatly  pre- 
dominant in  the  extensors,  and  that  the  muscles  of  the  arm  above  the 
elbow  were  not  affected,  decided  me  in  concluding  that  the  case  was 
not  one  resulting  from  pressure  on  the  brachial  plexus.  The  further 
fact  that  there  was  a  slight  blue  line  visible  along  the  gums  convinced 
me  that,  notwithstanding  the  absence  of  any  history  of  contamination  by 
lead,  the  case  was  one  of  that  disease.  The  patient  was  a  beer-dvinker, 
1  "  Lecons  de  clinique  medicale,"  Taris,  1809,  p.  492. 


PLUMBISM.  893 

and  might,  I  conceived,  have  become  i   in  that    way,  as  had 

others  in  my  experience. 

In  lead-colic  the  character  of  the  pain  and  its  situation  may  be  of 
service  in  the  formation  of  a  diagnosis,  but  the  main  reliance  must  be 
upon  the  antecedents  of  the  patient,  and  the  coexisting  evidences  of 
plumbism  to  which  attention  has  already  been  directed. 

These  circumstances  are  likewise  what  must  govern  us  in  lead-anais- 
thesia  and  hyperesthesia.  » 

Prognosis. — This  is  not  unfavorable  except  as  regards  the  c<  i 
manifestations,  provided  the  patient  can  be  submitted  to  proper  treat- 
ment and  removed  from  all  exposure  to  lead-poisoning.  Lead-encephu- 
lopathy  is  the  most  serious  of  all  the  forms  of  plumbism,  and  this  is  es- 
pecially the  case  when  there  is  a  combination  of  delirium,  convulsions, 
and  coma.  Of  seventy-two  cases  observed  by  Tanquerel  dee  Plan 
sixteen  were  fatal.  It  was  probably  more  apt  to  terminate  in  death  in 
his  day  than  now,  when  the  hygienic  and  therapeutical  relations  of 
plumbism  are  better  understood.  Recovery  ensued  in  all  of  the  cases 
occurring  in  my  experience. 

In  lead-paralysis  the  prospect  of  recovery  depends  altogether  on  the 
ability  to  produce  contractions  in  the  paralyzed  muscles  by  electricity. 
If  the  induced  current  will  effect  them,  the  cure  will  be  rapid;  if  the 
interrupted  primary  current  is  required,  a  longer  time  nan  -be- 

fore success  is  attained  ;  but,  if  the  muscles  will  not  react  to  either  the 
induced  or  primary  currents,  a  favorable  result  is  not  to  be  « 
The  extent  of  the  atrophy  is  also  an  important  element  in  the  p 

In  lead-colic,  hyp  ia,  and  anaesthesia,  the  prospect  of  r 

ery  is  good,  provided  the  f  hygienic  and  therapeutical  indica- 

tion 

Morbid  Anatomy  and  Pathology. — Very  little  is  known  relative  to 
the  i  naioiny  of  plumbic  affections.     In  the  several  forms  with 

which  we  are  acquainted,  the  uervous  system  rarely  presents  evidei 
of  any  Lesion  which  can  be  regarded  as  characteristic.     In 
lead-encephalopathy,  however,  there  baa  been  found  a  flatfr  aed,  indu- 
rated, ami  atrophied  condition  of  the  brain,  and  in  others  the  indica- 
tions of  inflammation  and  softening. 

In  the  case  of  a  painter  who  had  suffered  from  repeat  d 

lead-colic,    and    who  finally   died    with    head->ympi  >m~      dt  lii  ium,  epi- 
lepsy    reported   by  BIM.  Gueneau  de  Massy  and   Leinaire,  the   i 
mortem  examination  showed  the  existence  of  a  large  extravasation, 
!i  had  broken  through  the  cerebral  tissue  From  the  circumfen 

to  the  fourth  ventricle. 

Gombaull  '  recently  reported  a  case  of  lead-paralysis  in  which,  on 
1  .  i 


894  TOXIC   DISEASES   OF   THE   NERVOUS   SYSTEM. 

post-mortem  examination,  the  spinal  cord  and  the  nerve-roots  were 
found  to  be  unaltered,  but  in  some  of  the  peripheral  nerves  the  medul- 
lary substance  was  separated  into  granules,  though  the  axis-cylinder 
was  normal. 

Westphal '  has  discovered,  in  a  case  of  lead-paralysis,  a  similar  con- 
dition of  the  radial  nerve.  In  this  case  the  spinal  cord  and  the  nerve- 
roots  were  unchanged. 

Jn  a  case  of  lead-poisoning  in  whfch  there  had  been,  during  life,  colic, 
vomiting,  diarrhoea,  and  finally  collapse,  Kussmaul  andMaier9  found 
sclerosis  of  the  cceliac  and  superior  cervical  ganglia  of  the  sympathetic 
and  periarteritis  in  the  brain  and  spinal  cord. 

Lead  has  been  detected,  in  cases  of  plumbism,  in  the  tissue  of  the 
brain,  spinal  cord,  and  nerves.  In  fact,  it  appears  to  have  a  special 
affinity  for  the  nerve-substance. 

It  is  probable  that,  except  in  extreme  cases,  or  in  very  exceptional 
instances,  the  changes  in  the  brain,  spinal  cord,  nerves,  and  sympa- 
thetic system  are  not  such  as  are  discoverable  by  our  present  means  of 
research,  just  as  are  the  alterations  produced  by  opium,  alcohol,  hydro- 
cyanic acid,  strychnia,  and  other  substances. 

The  muscles,  in  cases  of  lead-paralysis,  have  been  examined  by  An- 
tral,3 Gendrin,*  Tanquerel  des  Planches,6  and  others,  and  analogous 
results  obtained.  The  fibres  have  been  found  to  be  pale  and  yellowish, 
to  be  friable,  atrophied,  and  desiccated.  I  have  repeatedly  removed 
small  portions  with  Duchenne's  trocar,  and  have  always  found  the 
transverse  stria?  disappearing,  and  fatty  degeneration  making  its  ap- 
pearance. 

The  hypothesis  that  the  affection  is,  primarily,  one  of  the  muscles, 
is  not  supported  by  facts  ;  those  cases  of  apparent  loss  of  muscular 
irritability,  resulting  from  certain  poisons,  adduced  by  Longet, 
Bernard,  Mitchell,  myself,  and  others,  were  simply  instances  in 
which  the  loss  of  nervous  irritability  took  place  from  the  periphery  to 
the  centre. 

Facts,  too,  are  against  the  notion  that  the  lead  acts  by  contact  with 
the  muscles,  and  the  circumstance  of  the  paralysis  occurring  so  gener- 
ally in  the  hands  of  painters,  for  instance,  is  adduced  in  proof.  But  we 
have  seen  that  the  left  hand  is  just  as  frequently  affected  as  the  right, 
while  it  is  certainly  less  in  contact  with  the  lead.  Moreover,  those 
cases  of  paralysis  in  the  extensors  of  the  hand  which  have  resulted 
from  hair-dyes  and  other  cosmetics,  are  altogether  against  the  hypothe- 
sis in  question. 

1  Archiv  fur  Psychiatric,  Band  iv.,  18*74. 

2  Deutsche*  Archiv  fur  klin.  Med.,  Band  ix.,  H.  2. 

3  "  ('Unique  M6dicale,"  tome  ii.,  p.  227. 

4  "Maladies  dc  l'cncephale,"  par  Abcrcrombie,  traduction,  second  edition,  p.  5*76. 
6  Op.  (At.,  pp.  11,  144,  149. 


PLUMBI8M.  895 

In  casos  of  lead-colic  there  appear  to  be  no  anatomical  changes  in 
the  intestines  which  can  be  reasonably  associated  with  the  phenomena 
of  the  disease  as  their  cause. 

Treatment. — In  the  treatment  of  plumbism  there  are  certain  princi- 
ples to  be  acted  upon  in  all  the  affections  embraced  within  its  limii<. 
One  of  these,  the  prophylaxis,  belongs  to  the  domain  of  hygiene,  and 
therefore  need  not   be  here  considered;  the  other,  the  removal  of  th 
lead  from  the  system,  demands  our  first  car". 

The  researches  of  Melscns  have  shown  that  in  the  iodide  of  potas- 
sium we  have  an  agent  which  separates  the  lead  contained  in  the  tis- 
sues from  its  combinations,  and  forms  with  it  an  iodide  of  lead,  under 
which  form  it  is  excreted  from  the  organism  by  the  kidneys. 

Some  authors  advise  caution  in  the  use  of  the  iodide  of  potassium, 
on  the  ground  that  the  resulting  compound  is  very  poisonous,  and  may 
produce  highly-deleterious  effects.  In  a  great  many  cases  of  lead-pa- 
ralysis and  other  consequences  of  lead-poisoning  in  which  I  have  given 
the  iodide,  I  have  never  seen  the  least  untoward  result,  and  I  always 
use  it  in  large  doses  from  the  beginning.  In  many  cases  the  lead  can 
b<-  readily  detected  in  the  urine,  and  the  blue  line  around  the  gums 
disappears  quickly  under  its  use.  If  there  is  great  debility,  or  if  the 
cachexia  be  marked,  iron,  quinine,  and  strychnia,  may  be  employed  with 
advantage. 

In  the  treatment  of  lead-encephalopathy,  the  free  administration  of 
the  iodide  of  potassium  combined  with  the  bromide  affords  the  best 
prospect  of  success. 

In  attacks  of  lead-colic,  the  hypodermic  injection  of  morphia,  in 
-,  sufficient  t<>  keep  the  pain  in  cluck  while  the  iodide  of  potassium 
is  doing  it .s  work,  with  an  occasional  purgative,  will  generally  be  all  the 
treatment  required. 

But  in  lead-paralysis  the  loss  of  power  remains,  and  would  continue 
indefinitely,  without  the  use  of  measures  directed  specially  against  it  : 
chief  among  these  is  electricity.  The  farad  aic  current,  if  it  will  cause 
the  muscles  to  contract,  is  to  be  preferred.  Each  paralyzed  muscle 
must  be  acted  on  for  two  or  three  minutes  every  day.  bo  thai  for  both 
npp<  ities  the  duration  of  a  siana   would  vary  from  a  half  to 

three-quarters  of  an  hour.     In  ordinary  cases  two  months  will  suffice 
ire. 

Bui  ;t  often  happens  thai  the  electric  contractility  of  the  para 
lv/.cd   musclt  completely  abolished   thai   the  faradaic  currenl 

is  without   effect.      In   Buch  cases  the   interrupted    galvanic  currenl 
musi   be  used,  and  continued  till,  as  will  eventually  be  the  case,  tin 

i  laic  currenl  •  extractions.      I   ha\  e  ni  \  ■  n  in 

which  the  galvanic  current  would  not   produce  contractions,     One  of 
the  worst  examples  of  the  affection  in  question   I  ever  sa*  »^  the 

patient   who  f  nuied  the  Bubjecl  of   R  clinical  lecture  to  the  class  at   tin 


896  TOXIC   DISEASES   OF   THE   NERVOUS   SYSTEM. 

Bellevue  Hospital  Medical  College.1  His  improvement  under  the 
circumstances  was  rapid,  and  he  eventually  was  able  to  earn  his  liv- 
ing again.  Faradaic  currents  of  great  power  failed  to  produce  con- 
tractions, and  but  for  the  use  of  the  galvanic  current  he  would  have 
been  incurable. 

If  the  galvanic  current  fails  to  act  on  the  muscles,  success  is  out  of 
the  question. 

In  addition  to  electricity,  frictions,  kneading  the  muscles,  and  pas- 
sive exercise,  are  useful.  Contractions  may  be  overcome  by  suitable 
prothetic  apparatus. 

In  a  case  under  the  care  of  Prof.  Sayre,  and  which  I  had  the 
opportunity  of  seeing,  the  patient,  a  young  lady,  was  able  to  play  the 
piano — though  paralyzed  in  both  hands — by  means  of  an  admirable 
appliance  devised  by  Dr.  E.  D.  Hudson,  of  this  city. 

In  the  treatment  of  lead-ana3sthesia  and  hyperesthesia,  the  iodide 
of  potassium  conjoined  with  the  use  of  the  galvanic  or  faradaic  cur- 
rent to  the  affected  parts  will  generally  prove  sufficient  to  effect  a  cure. 


CHAPTER    II. 

ALCOHOLISM. 

Alcoholism — under  which  term  I  do  not  now  propose  to  embrace 
the  condition  called  drunkenness,  the  immediate  result  of  the  ingestion 
of  a  large  quantity  of  alcohol — is  exhibited  under  two  somewhat  differ- 
ent forms.  One  of  them  is  the  permanent  state  which  exists  in  persons 
who  habitually  imbibe  excessive  amounts  of  alcohol,  and  is  known  as 
chronic  alcoholic  intoxication  or  chronic  alcoholism.  The  other  is  a 
paroxysm,  the  result  of  still  greater  excess,  or  the  sudden  stoppage  of 
the  stimulus  to  which  the  system  has  become  habituated,  and  is  desig- 
nated by  various  names,  such  as  delirium  tremens,  mania  a potu,  or 
more  properly  acute  alcoholism. 

a.  Chronic  Alcoholism. — The  attention  of  the  medical  profession 
was  first  prominently  directed  to  the  subject  of  chronic  alcoholism  by 
Dr.  Magnus  Huss,2  of  Stockholm,  in  1849.     In  my  description  of  the 

1  Journal  of  Psychological  Medicine,  January,  18*71,  p.  43. 

4  Dr.  Huss's  work,  being  printed  in  Swedish,  is  to  a  great  extent  unread  outside  of  Scan- 
dinavia.  Two  very  excellent  articles,  embracing  a  full  synopsis  of  his  work,  were  pub- 
lished in  the  British  and  Foreign  Medico- Chirurgical  Review,  in  1851  and  1852.  I  shall 
also  draw  largely  from  an  address  on  "  The  Effects  of  Alcohol  upon  the  Nervous  System," 
which  I  delivered  May  4,  1874,  on  assuming  the  presidency  of  the  New  York  Neurological 
Society,  and  which  was  published  in  the  Psychological  and  Medico-Legal  Journal,  for  July, 
1874. 


ALCOHOLISM.  897 

disorder,  I  shall,  to  a  great  extent,  avail  myself  of  his  thorough  obser- 
vations. 

Symptoms. — In  one  group  of  cases  resulting  from  the  long  use  of 
intoxicating  liquors,  the  principal  manifestations  of  the  disease  relate  to 
the  muscular  system.  Tremor  and  unsteadiness,  especially  of  the  up- 
per extremities,  are  among  the  first  symptoms.  Subsequently  the  lower 
limbs  are  affected,  and  then  the  muscles  of  the  trunk.  These  phenom- 
ena are  most  marked  in  the  morning,  before  the  patient  has  had  his 
accustomed  dram. 

In  other  cases  the  tremor  is  not  a  very  prominent  feature,  though, 
as  far  as  my  experience  goes — and  it  is  by  no  means  inconsiderable- - 
no  patient  with  the  disorder  in  question  is  free  from  a  tremulous  agita 
tion  of  his  muscles  when  he  attempts  to  make  a  voluntary  movement. 
But  it  may  not  be  well  marked,  and,  instead  of  it,  the  individual  obsi  >i 
that  he  cannot  hold  things  as  well  as  he  once  did.  Objects  which  he 
takes  hold  of  fall  from  his  hands  without  his  being  able  to  retain  them. 
If  he  does  exert  himself  to  avoid  this  inconvenience,  the  hands  ar.- 
seized  with  an  involuntary  trembling,  which  he  calls  "  nervousness," 
and  which  he  endeavors  to  cure  by  fresh  potations.  From  this  feeble- 
ness or  paresis  the  distance  to  paralysis  is  not  groat. 

I  had,  not  long  ago,  a  case  under  my  charge  in  which  the  patient,  a 
gentleman  of  admitted  eminence  in  his  profession,  clearly  suffering  from 
chronic  alcoholism,  could  hold  nothing  in  his  hands  unless  he  kept  his 
eyes  fixed  upon  them.  The  moment  he  ceased  to  look,  the  object  fell 
to  the  ground.  In  the  present  treatise  I  have  referred  to  several  in- 
stances of  this  curious  condition  which  were  due  to  other  causes. 

The  lower  extremities  eventually  become  affected,  and  the  patient 
may  entirely  lose  the  power  of  locomotion.  The  nerves  of  sensation 
also  become  involved,  and  there  are  various  abnormal  feelings,  consti- 
tutinsr  one  or  more  of  the  forms  of  anaesthesia.  Vertiiro  and  dimness 
of  vision  may  also  be  present. 

This  type  of  the  disease  Dr.  IIuss  calls  the  paralytic 

In  the  next  form,  or  the  anaesthetic,  the  phenomena  are  more  di- 
rectly connected  with  perverted  or  lost  sensibility  from  the  outset.  The 
extremities  first  become  affeoted,  and  subsequently  the  oentral  pan 
the  body.  In  the  beginning  the  patient  experiences  a  difficulty  in  de- 
termining from  the  feel  the  nature  of  the  object  he  has  laid  hold  of,  or 
against  which  his  fool  may  have  struck.  But  in  a  more  advanced  si 
he  loses  all  sense  of  pain,  and  pins  may  be  thrust  into  hisskin,  or  ■  ooal 
of  fire  dropped  upon  it  without  his  experiencing  any  discomfort.  With 
the  anaesthesia  there  is  always  loss  of  motor  power. 

The  sesthesiometer,  the  application  of  whioh  instrument  topraotioal 

medicine    18  of   more    recent    date  than  I  >r.   Hugs'  tions,  enables 

US  to  detect  incipient    loss    of   sensibility  at    a    very  earlj    Stage   of 
I  ion. 

58 


898  TOXIC   DISEASES   OF   THE  NERVOUS  SYSTEM. 

Symptoms  connected  with  this  category  of  cases  which  I  have  no- 
ticed, but  which  are  not  alluded  to  by  Dr.  Huss,  are  that  the  senses  of 
sight,  hearing,  smell,  and  taste,  are  also  often  involved. 

Another  singular  phenomenon  which  I  have  observed  in  these  cases, 
which  is  referred  to  by  Magnan,1  and  also  quite  recently  by  Virenque,3 
is  that  the  loss  of  sensation  involves  only  one  lateral  half  of  the  bod}% 
This  hemi-anassthesia  is  met  with  in  several  other  morbid  conditions, 
notably  as  we  have  seen  in  hysteria.  The  other  special  senses  are  gen- 
erally implicated.  Thus  the  patient  loses  the  sight  of  one  eye  ;  cannot 
hear  with  one  ear  ;  can  taste  the  most  strongly  sapid  substances  with 
only  one  half  of  the  tongue,  and  perceive  the  most  penetrating  odors 
with  only  one  nostril.  In  one  case  cited  by  Magnan,  the  patient,  who 
had  long  been  addicted  to  the  excessive  use  of  alcoholic  liquors,  and 
subsequently  to  the  use  of  absinthe,  had  hallucinations  and  delusions  in 
addition  to  the  hemi-anoesthesia,  and,  what  is  unusual,  complete  loss  of 
sensation  in  the  cornea  of  one  eye,  although  tears  were  excited  in  both 
eyes  when  the  affected  one  was  touched  by  the  finger. 

In  the  third  form  of  chronic  alcoholism,  convulsions  constitute  a 
prominent  feature,  though  they  are  not  generally  among  the  first  symp- 
toms. I  have,  however,  witnessed  several  cases  in  which  epileptiform 
seizures  were  the  immediate  and  direct  consequence  of  the  excessive 
use  of  alcoholic  liquors,  and  in  which  there  had  been  no  well-marked 
premonitory  symptoms.  But  in  the  great  majority  of  instances  there 
are  derangements  of  motility  and  of  sensibility,  such  as  have  just  been 
described,  and  then  the  gradual  supervention  of  convulsive  jerkings  of 
the  muscles,  similar  to  those  which  occur  in  convulsive  tremor  and 
chorea,  combined  with  painful  tonic  contractions  or  cramps.  After  a 
time  the  spasms  are  accompanied  with  loss  of  consciousness,  and  hence 
are  more  truly  epileptic  in  character.  Dr.  Huss  noticed  that  as  the 
condition  of  chronic  alcoholism  became  more  profound  there  was  a  ten- 
dency toward  the  disappearance  of  the  convulsions,  and  that  at  last 
they  ceased  entirely. 

In  the  next  and  last  variety  of  the  affection  there  is  a  general  hyper- 
aesthetic  condition  of  the  skin  and  other  special  organs  of  the  senses. 
The  least  touch  causes  intense  pain  ;  bright  lights  are  unendurable, 
and  even  the  diffused  light  of  a  moderately  illuminated  room  is  pain- 
ful. Very  gentle  noises  cause  great  discomfort,  and  loud  sounds  are 
agonizing.  Even  the  smell  and  taste  are  exaggerated,  and  occasionally 
perverted  to  the  extent  of  illusions. 

In  whatever  form  chronic  alcoholic  intoxication  may  manifest  itself, 
there  are  occasionally  notable  symptoms  present  which  do  not  con- 

1  "  De  Talcoolisme,  des  diverses  formes,  du  delire  alcoolique  et  dc  leur  traitement," 
Paris,  1874. 

4  "De  la  perte  de  la  sensibilite  geneiale  et  speciale  d'un  cote"  du  corps,"  etc.,  Paris 
1874. 


ALCOHOLISM.  £99 

stitute  ordinary  features  of  the  disease.  Thus  there  may  be  double 
vision,  from  paralysis  of  one  of  the  ocular  muscles,  usually  the  internal 
rectus,  in  which  case  there  is  ptosis  also  ;  or  the  muscles  concerned  in 
articulation  are  involved,  and  speech  becomes  imperfect  or  impossible  ; 
or  those  by  which  swallowing  is  effected  are  paralyzed,  or  there  is  vio- 
lent palpitation  of  the  heart,  or  intense  neuralgic  pain  in  one  or  more 
parts  of  the  body.  To  touch  on  all  these  complications  would  require 
more  space  than  I  have  at  my  disposal.  But  the  mental  synq  ' 
which  form  more  or  less  prominent  characteristics  of  all  cases  of  chronic 
alcoholism  require  a  somewhat  extended  notice.  The  perceptions,  the 
emotions,  the  intellect,  and  the  will,  are  all  implicated  to  a  greater  or  less 
extent.  Attention  has  already  been  called  to  the  aberrations  of  the 
perceptions  constituting  illusions  and  hallucinations.  The  emotions 
assume  an  undue  prominence,  especially  those  of  a  sorrowful  character, 
and  thus  the  individual  becomes  maudlin,  a  condition  which  I  should 
describe  as  consisting  in  a  disposition  to  lament  and  shed  tears  over 
imaginary  or  greatly  exaggerated  griefs.  It  is  rarely  the  case  in  my 
experience  that  the  subject  of  chronic  alcoholism  is  changed  from  a 
peaceable  to  a  quarrelsome  person,  or  from  a  timid  to  a  brave  one. 
The  alteration  is  almost  always  in  the  other  direction.  At  the  Bame 
time  it  is  not  to  be  denied  that  individuals,  whose  passions  are  vicious 
and  not  held  in  complete  subjection,  are  rendered  still  more  vicious  and 
uncontrollable  by  chronic  alcoholism.  Perhaps  the  most  oharaoteri 
feature,  as  regards  the  emotions  which  persons  suffering  from  t  lie  dis- 
ease in  question  exhibit,  is  irritability  of  temper.  This  is  Bhown  in  the 
fact  that  slight  circumstances,  which  in  a  state  of  health  would  cause 
DO  annoyance,  now  give  rise  to  great  vexation.  At  the  same  time, 
though  there  is  not,  as  I  have  said,  much  tendency  to  quarrel 
there  is  nevertheless  a  proneness  to  take  offense,  and  to  regard,  aa 
slights  and  insults,  acts  which  have  no  bearing  in  that  direction. 

Again,  tlere  is  intense   melancholy,  without   the   exisl  delu- 

sions, and  during  which  the  individual  may  attempt   suicide;  or  there 
may  be  indefinable  fear,  despair,  terror,  or  shame,  leading  to  the  pi 
trat ion  of  self-desl motion. 

The  more  purely  intellectual  qualities  of  the  mind  rarely  escape 
being  involved  in  the  general  disturbance.  The  power  of  application, 
of  appreciating  the  bearing  of  facts,  of  drawing  distinctioi  rcis- 

menl  aright,  and  even  of  comprehension,  are  all  mi 
impaired.    The  sense  of  right  and  justioe  which  the  individual  □ 
had  is  so  weakened  or  I  that  be  will  lie,  steal,  murder, 

mit  other  on  ..ii  when  there   is  no  tion,     [ndoed,thc 

of  motive  is  generally  ;i  counteracting  oiroumstao 

The  memory  is  among  the  first  facul  iiTer. 

Bui  in  addition  to  these  evidences  of  mental  deterioration  then 
dp  actual  aberration  of  mind,  as  shown  by  the  existence  of  d 


900  TOXIC  DISEASES  OF  THE  NERVOUS  SYSTEM. 

These  are  generally  of  a  depressing  character,  and  may  or  may  not  have 
their  origin  in  false  perceptions  of  the  senses.  These  delusions  may 
prompt  to  suicide  or  other  act  of  violence. 

The  will  is  always  lessened  in  force  and  activity.  The  ability  to 
determine  between  two  or  more  alternatives,  to  resolve  to  act  when 
action  is  necessary,  no  longer  exists  in  full  power,  and  the  individual 
becomes  vacillating,  uncertain,  the  prey  to  his  various  passions,  and  to 
the  influence  of  vicious  counsels. 

With  these  troubles  of  the  mind  there  are  almost  invariably  head- 
ache, vertigo,  and  persistent  wakefulness,  all  of  which  give  evidence  of 
the  extent  to  which  the  nervous  system  is  affected. 

All  writers  of  systematic  treatises  upon  insanity  have  called  atten- 
tion to  the  frequency  with  which  mental  aberration  is  caused  by  the 
excessive  use  of  alcoholic  liquors,  but,  in  a  recent  monograph,  M.  Mar- 
faing1  has  given  some  interesting  data  relative  to  the  characteristics  of 
the  insanity  produced  by  alcoholism.  Thus,  he  has  observed  that  the 
hallucinations  and  delusions  are  almost  always  of  a  painful  character. 
The  patient  sees  frightful  or  repulsive  objects,  armed  men  or  horrible 
animals;  he  sees  persons  lying  in  wait  for  him,  or  a  thousand  obstacles 
are  interposed  between  him  and  his  desires;  he  hears  menacing  voices, 
and  the  supplications  of  his  friends  for  help  from  dangers  which  en- 
compass them. 

Occasionally,  however,  the  imaginings  are  of  a  more  pleasant  char- 
acter. He  is  surrounded  with  flowers  and  fountains  ;  beautiful  women 
are  his  companions,  and,  though  his  generative  power  may  be  entirely 
extinct,  he  brags  of  his  conquests,  and  the  favors  which  are  showered 
upon  him. 

Another  characteristic  of  the  hallucinations  and  delusions  of  the 
mania  of  alcoholism  is,  their  changeability.  Scarcely  has  he  expressed 
one  delirious  conception  when  another  is  uttered,  and  so  on  for  days  at 
a  time. 

A  somewhat  peculiar  variety  of  chronic  alcoholism  is  that  produced 
by  the  drinking  of  absinthe,  a  habit  which  prevails  to  a  great  extent  in 
France,  and  which,  though  barely  naturalized  in  this  country,  has  a 
large  and  increasing  number  of  votaries. 

The  condition  in  question  has  been  well  studied  by  M.  Magnan a  by 
experiments  on  the  lower  animals  as  well  as  by  observations  in  man. 
The  main  fact  appears  to  be  that  absinthe  has  an  especial  proclivity  to 
produce  epileptic  convulsions,  in  addition  to  causing  the  other  phenom- 
ena due  to  the  highly-concentrated  alcohol  it  contains. 

Death    may   ensue    in  chronic  alcoholism,  from  the  accompanying 

1  "De  l'alcoolisme  considere  dans  ses  rapports  avec  l'alienation  mentale,"  Paris,. 
1875. 

8  "Etude  experimentale  et  clinique  sur  l'alcoolisme,"  Paris,  18*71;  also  "De  l'alcoo- 
lisme,"  Paris,  1874. 


ALCOHOLISM.  901 

morbid  conditions,  induced  in  the  brain  or  other  parts  of  the  nervous 
sj'stem  ;  from  exhaustion,  owing  to  the  direct  effects  of  the  poison,  or  to 
the  inability  of  the  stomach  to  digest,  and  the  assimilative  organs  to  ap- 
propriate the  food  taken  ;  or,  as  is  commonly  the  case,  from  the  super- 
vention of  some  intercurrent  affection  to  which,  owing  to  the  depressed 
condition  of  the  system,  the  patient  is  particularly  liable. 

b.  Acute  Alcoholic  Intoxication,  Delirium  Tremens.  Symptoms. — 
Among  the  first  symptoms  of  acute  alcoholism,  gastric  and  intestinal 
derangements  are  to  be  noticed.  Thus  there  are  anorexia,  nausea,  and 
vomiting,  especially  in  the  morning,  and  either  diarrhoea  or  obstinate 
constipation,  and  the  tongue  is  furred  and  dry.  The  pulse  is  usually 
rapid  and  feeble,  the  skin  cold  and  clammy,  and  the  general  powers  of 
the  system  much  reduced.  The  sleep  is  deficient  in  amount  and  is  dis- 
turbed by  frightful  dreams,  and  there  are  often  vertigo,  headache,  and 
confusion  of  ideas. 

At  a  very  early  period  tremor  is  present,  and  is  especially  manifested 
in  the  tongue,  which,  when  protruded  from  the  mouth,  cannot  be  held 
steady,  and  the  continual  action  of  which  is  further  shown  in  the  de- 
fective articulation  which  always  exists.  The  upper  extremities  and 
sometimes  the  head  are  also  the  seat  of  tremulous  movements. 

These  symptoms  gradually  increase  in  intensity,  and  other  phenom- 
ena are  soon  developed.  The  countenance  assumes  a  wild  expression, 
the  manner  becomes  hurried  and  anxious,  the  illusions,  hallucinations, 
and  delusions,  become  more  vivid,  and  they  are  almost  invariably  of  a 
terrifying  character.  Frightful  objects,  such  as  reptiles,  demons,  and 
other  horrible  figures,  are  perceived,  and  the  patient  covers  his  bead  in 
the  bedclothes  in  the  vain  endeavor  to  shut  out  the  sight  of  them, 
or  may  even  commit  suicide  in  the  effort  to  escape  from  the  imaginary 
dangers  which  threaten  him.  Hallucinations  of  the  other  sei 
also  sometimes  present.  The  temper  becomes  still  more  irritable,  :ind 
the  motility  is  increased  to  an  extreme  degree.  Sleep  is  no  longer  pos- 
sible, and  day  and  night  the  visions  and  delusions  are  ever  preseni  in 
some  form  or  other.  The  body  becomes  hot,  but  the  extremities  still 
remain  cold  and  clammy.  The  pulse  ranges  from  li)0  to  120  or  more, 
and  is  small  and  weak.  'The  mine  is  scanty  ami  high-oolored,  the  bow- 
els oonsl  ipated. 

During  all  this  period  tli<-  patient   talks  incessantly,  generally  with 

renoe  to  bis  hallucinations  and  delusions.     These  Latter,  though  well 

marked,  and  constant,  are,  Like  bis  erron s  perceptions,  changeable  ; 

and  it   rarely  happens  thai   they  oannot,  for  the  moment  at   Least,  be 
ated  by  a  few  words  from  those  around, 

The  pupils  are  usually  strongly  contracted,  and  if  the  fundus  of  the 
eye  be  examined  with  the  ophthalmoscope,  the  disk  and  retina  will  be 
found  ited.     Dr.  Clifford  Allbutt '  states  thai  be  makes  it  amis 

'"(in  the  Uee  of  the  Ophthalmoscope  in  Diseasea  of  tl     S  ' 

and  Hew  fork,  L871,  p.  258. 


902  TOXIC  DISEASES  OF  THE  NERVOUS  SYSTEM. 

to  examine  the  fundus  in  all  cases  of  delirium  tremens  which  come  un- 
der his  observation,  and  that  in  the  great  majority  of  cases  he  finds 
congestion  and  opalescence  of  the  disk,  and  full  retinal  veins. 

In  some  cases — especially  in  those  which  are  the  direct  result  of  the 
excessive  use  of  alcoholic  liquors,  and  not  the  consequence  of  a  sudden 
deprivation  of  an  accustomed  stimulus — convulsions  of  an  epileptiform 
character  may  occur  ;  usually  these  are  repeated  again  and  again. 
Death  may  take  place  during  their  continuance,  and  they  always  add 
greatly  to  the  gravity  of  the  situation. 

An  attack  of  acute  alcoholism  lasts  ordinarily  for  from  three  to  five 
days.  If  recovery  is  to  ensue  the  patient  obtains  a  little  sleep,  and 
awakes  with  a  decided  mitigation  in  the  violence  of  all  his  symptoms. 
If,  on  the  contrary,  death  is  to  result,  his  physical  powers  become  rap- 
idly exhausted,  the  delirium  becomes  low  and  muttering,  he  picks  at 
the  bedclothes,  he  passes  into  a  state  of  coma,  the  pulse  rises  still  higher 
in  frequency,  while  it  becomes  correspondingly  weaker,  the  bodily  tem- 
perature falls,  and  he  gradually  sinks  or  dies  from  a  renewal  of  the  con- 
vulsive seizures. 

Causes. — Though  the  abuse  of  alcohol  as  a  beverage  is  the  essential 
cause  of  alcoholism,  chronic  or  acute,  it  is  not  to  be  supposed  that  these 
conditions  are  induced  in  all  persons  who  use  alcoholic  liquors  to  ex- 
cess. Some  individuals  are  not  only  able  to  indulge  to  an  extreme 
degree  with  impunity,  but  may  even  live  to  old  age  in  the  enjoyment 
of  apparent  good  health.  Indeed,  when  Huss  published  the  results  of 
his  observations,  it  was  strongly  questioned  whether  the  symptoms 
which  he  had  noticed  were  not  due  to  the  impurities  which  the  whiskey 
generally  used  by  the  lower  classes  in  Sweden  is  known  to  contain,  rather 
than  to  alcohol.  Huss  admits  that  since  liquor  made  from  potatoes 
came  into  use,  and  especially  since  it  has  been  distilled  from  rotten  po- 
tatoes, chronic  alcoholism  has  become  much  more  frequent.  This  was 
attributed  to  the  fusel-oil  and  a  peculiar  substance  called  sticJc  •  but  it 
was  ascertained  that,  though  these  substances  may  have  aggravated  the 
symptoms,  they  were,  in  the  main,  produced  by  the  alcohol.  Many 
will  doubtless  call  to  mind  that  in  this  country  a  like  charge  has  been 
made  against  fusel-oil,  and  that  even  strychnia  has  had  the  reputation 
of  poisoning  whiskey  and  inducing  most  of  the  evil  effects  of  exces- 
sive alcoholic  potations. 

It  is  very  certain,  however,  that  alcoholic  intoxication  very  rarely, 
if  ever,  ensues  on  the  moderate  use  of  the  light  German  or  French 
wines,  or  of  those  made  in  this  country,  when  they  are  not  fortified  by 
the  subsequent  addition  of  spirit,  and  that  it  is  still  less  apt  to  occur 
from  the  temperate  use  of  malt  liquors. 

In  those  countries  in  which  wine  or  beer  is  the  chief  alcoholic  bev- 
erage, the  peculiar  conditions  which  have  been  described  are  rarely  met 
with.     Thus  Niemeyer  omitted  from  the  earlier  editions  of  his  work  on 


ALCOHOLISM.  003 

the  "  Practice  of  Medicine  "  all  reference  to  either  chronic  or  acute  alco- 
holism, and  a  chapter  was  afterward  specially  added  in  order  to  render 
the  work  more  useful  to  American  and  English  physicians,  for  whom  it 
was  translated  by  Dr.  C.  E.  Hackley,  of  this  city.  In  France,  also,  be- 
fore the  recent  increase  in  the  consumption  of  the  stronger  alcoholic 
liquors  and  absinthe,  neither  form  of  the  affection  under  notice  had 
attracted  much  attention.  Marfaing  begins  his  monograph,  to  which 
reference  has  already  been  made,  with  the  statement  that  previous  to 
the  last  twenty-five  years  alcoholism  was  hardly  known.  But  in  the 
northern  European  countries,  in  Great  Britain,  and  in  the  United  .States, 
where  whiskey,  uin,  rum,  and  brandy,  have  been  the  more  common  forms 
under  which  alcohol  has  been  ingested,  delirium  tremens  has  always 
been  a  prominent  disease,  and  the  chronic  form  doubtless  existed  long 
before  Huss  pointed  out  the  features  by  which  it  was  to  be  recognized. 

It  appears,  therefore,  that  what  are  called  the  spirituous  liquors  are 
more  powerful  in  causing  alcoholism  than  either  the  malt  or  vinous. 
This  is  probably  due  to  the  facts  that  more  alcohol  is  imbibed  with  the 
former  than  the  latter,  more  than  can  promptly  be  eliminated,  and  that, 
owing  to  its  concentrated  form,  greater  derangement  of  the  tissues, 
with  which  it  comes  in  contact,  is  produced.  It  is  thus  with  alcohol  as 
with  all  other  powerful  agents  taken  into  the  system. 

That  acute  alcoholism  or  delirium  tremens  results  directly  from  the 
excessive  ingestion  of  alcohol  is  admitted  by  all  writers  on  the  subject, 
but  they  are  not  so  generally  agreed  that  it  may  ensue  indirectly  from 
such  excessive  use,  by  the  individual  being  suddenly  deprived  of  the  ac- 
customed stimulus.  Thus  Ai;  aies  in  very  positive  terms  that 
delirium  tremens  may  occur  as  a  consequence  of  cessation  from  drink- 
ing, but  to  my  mind  any  one  who  I  the  disease  in  Boldiers,  sail- 
ers, or  prisoners,  will  be  slow  to  confirm  his  .statements  I  have  fre- 
quently seen  delirium  tremens  occur  in  soldiers  whose  debauches  have 
been  suddenly  interrupted  by  confinement  in  the  guard  house,  and  1  am 
quite  sure  that  most  army,  and  navy,  and  prison  medical  officers  have  had 
similar  experience.  V<  d  the  other  hand,  assigns  no  other  oa 
than  that  the  " habitual  stimulus  fa  liminished  or  abandoned  ; " 
but  i               [uently,  without  seeming  to  notice  the  bearing  of  the  i 

.111  instance  in  which  the  jiat  iciit  was  constantly  under  the  inllu- 

ence  of  alcoholic  li<|uor.     Dr.  Flint,'  however,  distinctly  r<  this 

dual  causation,  bul   the  i" : . . - 1  does  cot  appear  to  infl 
pat  oology  or  t  reatment. 

1  " Ti.  in.-,"  third  Am.  ii-  .ui 

Philadelphia,  1873. 

of  Physic,"  Phlladel 

phia,  1872,  vol.  i.,  p.  :;it. 

'  -  A   i  "        in..,"  third  edition,  1' 

phia,  It 


904  TOXIC  DISEASES  OF  TIIE  NERVOUS  SYSTEM. 

The  one  form  occurs  at  the  height  of  an  alcoholic  debauch  ;  the 
other  results  -when  the  system,  habituated  to  large  and  repeated  doses 
of  alcohol,  is  suddenly  deprived  of  a  stimulus  to  which  it  has  become 
thoroughly  habituated.  We  see  a  like  condition  induced  in  those  who, 
having  become  accustomed  to  the  ingestion  of  opium,  suddenly  or  too 
rapidly  leave  off  the  use  of  the  drug. 

In  their  therapeutical  relations  the  distinction  between  these  two 
modes  of  causation  is,  as  we  shall  hereafter  see,  important. 

Diagnosis. — The  clinical  history  as  well  as  the  peculiar  symptoms 
will  prevent  any  mistake  being  made  relative  to  the  real  character  of  a 
case  of  alcoholic  intoxication,  either  chronic  or  acute. 

Prognosis. — The  chronic  form  is  generally  successfully  treated  if  the 
patient  can  be  made  to  abstain  from  the  further  use  of  alcohol.  A 
paroxysm  of  the  acute  form  is  also  usually  recovered  from,  provided 
there  have  not  been  many  previous  attacks.  The  occurrence  of  con- 
vulsions is,  however,  a  serious  complication,  and  almost  invariably  cases 
in  which  they  take  place  terminate  fatally.  If  the  patient  abstains 
from  the  further  excessive  use  of  alcohol,  it  is  not  at  all  probable  that 
other  attacks  will  ensue. 

Of  course,  these  remarks  refer  to  alcoholism,  and  not  to  the  lesions 
in  the  stomach,  liver,  intestines,  heart,  and  other  organs,  which  may 
have  resulted  from  the  abuse  of  alcoholic  liquors,  but  which  are  not 
directly  connected  with  the  nervous  system. 

Morbid  Anatomy  and  Pathology. — The  most  common  patho-ana- 

tomical  condition  of  the  nervous  system  met  with  in  cases  of  alcoholism, 
chronic  or  acute,  is  congestion  of  the  cerebral  meninges  and  of  the  sub- 
stance of  the  brain.  This  alteration  is  especially  liable  to  affect  the 
vertical  surface.  An  effusion  of  serum  is  a  general  concomitant,  partic- 
ularly in  the  acute  form  of  the  disease — and  this  may  be  either  in  the 
subarachnoid  space  or  in  the  ventricles.  At  a  later  period,  if  the  ex- 
cesses be  continued,  the  dura  mater  may  become  chronically  congested, 
and  eventually  pachymeningitis  and  ha3matoma  are  developed. 

Or  the  repeated  or  continual  congestion  of  the  pia  mater  and 
arachnoid  may  result  in  the  production  of  a  chronic  inflammatory  pro- 
cess, attended  with  thickening  and  opalescence  of  these  membranes. 
The  vessels,  especially  the  veins,  are  gorged  with  blood,  and  there  may 
be  various  morbid  products,  such  as  serum,  pus,  or  sero-pus  effused. 

The  brain,  however,  presents  the  most  characteristic  alterations. 
These  appear  to  be  the  result  of  irritation  and  degeneration,  the  latter 
process  consisting  of  a  granular  or  fatty  disintegration  of  the  cerebral 
tissue,  generally  most  marked  in  the  cortical  substance. 

Dr.  John  C.  Peters,1  of  New  York,  was  among  the  first  to  make 
careful  and  systematic  observations  of  the  post-mortem  appearance  of 

1  "  On  tli«  Pathological  Effects  of  Alcohol,"  New  York  Journal  of  Medicine,  vol.  iii., 
1844,  p.  335. 


ALCOHOLISM.  905 

individuals  who  had  died  from  the  excessive  use  of  ardent  spirits.  As 
regards  the  brain,  he  found  that  "  invariably  there  was  present  more  or 
less  congestion  of  the  scalp  and  of  the  membranes  of  the  brain,  with 
considerable  serous  effusion  under  the  arachnoid,  while  the  substance  of 
the  brain  was  unusually  white  and  firm,  as  if  it  had  lain  in  alcohol  for 
an  hour  or  two,  and  the  ventricles  were  quite  empty.  In  not  more  than 
eight  or.  ten  instances  did  we  find  more  red  spots  upon  the  cut  surface 
of  the  brain  than  usual.  The  peculiar  firmness  of  the  brain  was  noticed 
several  times,  even  when  decomposition  of  the  rest  of  the  body  had 
made  considerable  advance." 

Such  changes  as  are  described  cannot  result  entirely  from  co 
tion,  but  must  be  ascribed,  in  great  part,  to  the  direct  action  by  contact 
of  alcohol  on  the  brain-substance.  It  will  presently  be  shown  how 
strong  is  the  affinity  of  alcohol  for  this  tissue.  As  Carpenter '  remarks, 
alcohol  passes  into  the  brain  and  changes  both  its  chemical  and  physi- 
cal properties.  It  would  be  strange  indeed,  therefore,  if  with  alteration 
of  structure  there  were  not  also  aberrations  of  function. 

The  experiments  of  Dr.  Percy a  have  often  been  brought  forward  as 
proving  something  in  regard  to  alcohol  which  was  not  true  of  any  other 
substance.  This  observer  injected  strong  alcohol  into  the  stomachs  of 
dogs.  The  quantity  varied  from  two  to  six  ounces.  Death  followed, 
and  upon  examining  the  blood  and  brain  for  alcohol  it  was  always 
found.  The  presence  of  alcohol  in  the  blood  and  brain,  to  those  who 
look  superficially  or  ignorantly  at  the  matter,  has  rather  a  horrible 
aspect  ;  but  when  we  know  that  there  is  no  substance  capable  of  being 
absorbed  by  the  stomach  and  intestines  whioh  cannot  also,  by  proper 
means,  be  detected  in  the  blood  and  viscera,  the  subject  loses  much  <>f 
its  striking  character.  Dr.  Percy  used  alcohol  of  850°  specific  gravity, 
\s  bich  represents  a  mixture  containing  about  eighty  per  cent,  of  absolute 
alcohol.  As  the  strongest  brandy  and  whiskey  contain  but  about  fifty- 
four  .  of  alcohol,  the  concentrated  character  of  the  liquor  used 
by  I  >r.  I  '•  srey  is  at  once  seen.  In  one  case  six  ounces  were  injeoted  into 
the  stomach  of  ;i  dog,  ;i  quantity  amply  sufficient  to  cause  death  in  an 

adult   man. 

Many  other  physiologists  have  detected  alcohol  in  the  blood  and 

ra  of  animals  after  its  ingestion  into  the  stomaoh, 

I  have  several  times  performed  experiments  wit!  i  this 

point,  and  have  never  fail  guise  the  pn  alcohol  in  the 

I,  brain,  the  stomach,  expired  air,  and  urine  ■  whioh  I  bad 

administered  strong  aloohol ;  but,  when  using  liquors  containing  from 

it   t<>  fifteen  |  .  "f  alcohol,  such  ;is  the  German,  FVenoh,  and 

holio  l.i'pi'  '  I 

I  d  Experimental  [nquiry  oono<  rail  ' 


906  TOXIC  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Spanish  wines,  I  have  never  been  able  to  find  it  in  the  solids,  though 
detecting  it  readily  in  the  products  of  respiration. 

It  is  not  to  be  doubted,  therefore,  that  alcohol,  like  other  sub- 
stances, is  absorbed  into  the  blood,  and  exerts  its  influence  on  the  sys- 
tem through  the  medium  of  this  fluid. 

Pure  alcohol  is  a  violent  poison.  In  the  dose  of  less  than  one  ounce 
1  have  seen  it  cause  death  in  a  medium-sized  dog,  and  many  cases  are 
on  record  of  fatal  effects  being  immediately  produced  in  the  human 
subject  after  comparatively  small  quantities  have  been  swallowed. 
When  diluted,  its  effects  are  not  so  rapidly  manifested,  and  from  this 
form,  when  taken  in  sufficient  quantity,  the  condition  known  as  intoxi- 
cation is  produced.  Previous  to  this  point  being  reached  the  nervous 
and  circulatory  systems  become  excited,  the  mental  faculties  are  more 
active,  the  heart  beats  fuller  and  more  rapidly,  the  face  becomes 
flushed,  and  the  senses  are  rendered  more  acute  in  their  operation.  If 
now  the  further  ingestion  be  stopped,  the  organism  soon  returns  to  its 
former  condition,  without  any  f eeling  of  depression  being  experienced  ; 
but,  if  the  potations  are  continued,  the  complete  command  of  the  facul- 
ties is  lost,  and  a  condition  of  temporary  insanity  is  produced.  If 
further  quantities  be  imbibed,  a  state  of  prostration,  marked  by  coma 
and  complete  abolition  of  the  power  of  sensation  and  motion,  follows. 
Such  is  a  brief  outline  of  the  obvious  symptoms  which  ensue  upon  the 
use  of  alcoholic  liquors  in  considerable  quantities.  When  taken  in 
amounts  less  than  are  sufficient  to  induce  any  marked  effect  upon  the 
circulatory  and  nervous  systems,  there  is,  nevertheless,  an  influence 
which  is  felt  by  the  individual,  and  which  is  mildly  excitatory  of  the 
mental  and  intellectual  faculties. 

The  very  important  physiological  relations  of  alcohol  scarcely  come 
within  the  scope  of  this  treatise  ;  but  the  pathological  conditions  which 
result  from  it  are  of  importance  in  the  present  connection,  and  may 
therefore  profitably  engage  a  share  of  our  attention. 

The  general  action  of  a  large  dose  of  this  substance  is  shown  in  the 
following  experiment  : 

I  caused  a  dog  to  take  into  its  stomach  three  ounces  of  strong  alco- 
hol, diluted  with  a  corresponding  quantity  of  water.  Immediately  on 
receiving  it,  the  animal  retired  to  a  corner  of  the  room  and  lay  down. 
At  the  end  of  five  minutes  I  endeavored  to  make  it  walk  about  the 
apartment,  but  it  did  so  with  evident  reluctance,  though  up  to  this 
time  the  gait  was  not  staggering.  I  should  have  stated  that  I  detected 
alcohol  in  the  expired  air  in  forty-eight  seconds  after  administering  the 
liquid. 

After  eight  minutes  the  dog  walked  with  some  difficulty,  and  on 
carefully  examining  the  gait  I  found  that  the  posterior  extremities  were 
beginning  to  be  paralyzed.  This  paralysis  gradually  increased,  the  gait 
became  more  and  more  staggering,  and  at  the  end  of  fourteen  minutes 


ALCOHOLISM.  Ol)? 

the  animal  could  no  longer  stand.  The  paralysis  had  now  reached  the 
anterior  extremities. 

Sensibility  was  still  present,  though  evidently  lessened  in  acuteness; 
loud  noises  were  perceived,  and  the  eyes  were  involuntarily  closed  when 
the  motion  of  striking  was  made  before  them.  The  respiration  was 
hurried,  and  the  action  of  the  heart  was  greatly  accelerated. 

The  pupils  were  at  first  contracted,  but  became  dilated  in  about  fif- 
teen minutes,  and  remained  in  that  condition  throughout  the  experin 

In  thirty  minutes  the  animal  was  in  a  state  of  profound  coma.  E 
bility,  even  of  the  cornea,  was  abolished;  the  limbs  were  in  a  state  of  com- 
plete resolution;,  the  respiration  was  hurried;  the  heart  beat  rapidly  but 
feebly  ;  the  urine  and  fasces  passed  involuntarily,  and  the  temperature, 
as  indicated  by  a  thermometer  placed  in  the  rectum,  had  fallen  from  101° 
1'ahr.,  which  it  was  before  the  ingestion  of  the  alcohol,  to  98.5°  Fahr. 

The  animal  remained  in  a  comatose  condition,  and  died  one  hour 
and  twenty-two  minutes  after  the  ingestion  of  the  alcohol. 

In  this  experiment  the  alcohol  was  administered  in  such  a  large  dose 
that  the  period  of  excitation,  which  generally  follows  in  a  few  minutes, 
was  masked  or  altogether  prevented.  In  the  following  experiment,  the 
quantity  was  smaller,  and  the  secpience  of  phenomena  Mas  more  regular. 

I  introduced  into  the  stomach  of  a  large  dog  one  ounce  of  alcohol, 
diluted  as  before. 

Nothing  occurred  worthy  of  notice  during  the  first  live  minutes. 
Then  the  heart  was  accelerated,  as  was  also  the  respiration,  and  the 
pupils  became  contracted.  Sensibility  and  tin-  power  of  motion  were 
unaffected. 

In  twelve  minutes  the  gait  of  the  animal  became  uncertain,  the  Iimbfl 
were  lifted  higher  than  was  natural,  and  the  body  swayed  from  Bide  to 
side,  and  occasionally  strong  efforts  had  to  be  made  to  maintain  the 
erect  position.     The  pupils  were  still  contracted,  and  sensibility  ap- 

;■  id  to  be  intact. 

This  condition  lasted  twenty-two  minutes,  and  then  the  pupils  began 
to  dilate.     The  posterior  extremities  wen-  bo  Ear  weakened  as  to  render 
ii  ition  Impossible,  and  the  sensibility  <>!'  the  posterior  parts  of  the 
body  wub  materially. impaired  ;  the  i  m  was  very  irregular,  some- 

times being  quite  rapid,  then  c  onds,  and  then  be- 

coming slow.     The  pulse  was  still  rapid,  bul  weaker  than  at  first.     In 

B  little  LOSS  than  an  hour  the  animal  was  in  a  Btate  of  Ugh1  OOma,  which 

lasted  aboul  twenty  minutes.  Recovery  took  place  gradually,  the  phe- 
nomena of  intoxication  disappearing  in  an  inverse  order  to  their  super- 
vent  ion. 

Observati  >n  of  the  -;  mptoms  which  ensue  when  alcohol  in sufl 
quantity  is  given  to  animals  shows  thai  the  condition  oi  ition 

.  ,  Marvaud1  proposes,  be  divided  into  three  periods  or  staj 

I  U  |  • 


908  TOXIC  DISEASES  OF  THE  NERVOUS  SYSTEM. 

1.  Period  of  Excitation. — Uncertainty  in  the  movements,  accelera' 
tion  of  pulse  and  of  respiration,  contraction  of  the  pupils. 

2.  Period  of  Perversion. — Muscular  paralysis,  beginning  in  the  pos- 
terior extremities,  irregularity  of  pulse  and  of  respiration,  dilatation  of 
the  pupils. 

3.  Period  of  Collapse. — Complete  paralysis  of  motion,  anaesthesia, 
feebleness  of  the  pulse  and  of  respiration,  stoppage  of  respiration  and 
of  the  heart's  action,  death. 

Now,  I  was  desirous  of  knowing  how  much  of  this  condition  was 
due  to  the  presence  of  alcohol  in  the  brain,  and  how  much  to  disturb- 
ance in  the  quantity  of  blood  normally  present  in  this  organ.  In  other 
words,  I  wished  to  ascertain  whether  alcohol  increased  or  diminished 
the  amount  of  blood  circulating  within  the  cranium.  For  this  purpose 
I  performed  the  following  experiment  : 

I  trephined  a  dog,  and  secured  a  cephalohasmometer  into  the  open- 
ing made  by  the  trephine  in  the  skull.  I  then  administered  an  ounce 
of  alcohol,  diluted  as  in  the  previous  experiment.  In  fifty  seconds  I 
detected  alcohol  in  the  expired  air  ;  in  four  and  a  half  minutes  the  res- 
piration was  accelerated,  the  action  of  the  heart  became  more  rapid 
and  strong,  and  the  pupils  were  beginning  to  contract.  Still  there  was 
no  increase  in  the  intracranial  pressure,  and  I  therefore  knew  that  up 
to  this  time  the  amount  of  blood  in  the  brain  had  not  been  increased. 
In  six  minutes  and  a  half  the  dog's  gait  was  staggering,  and,  though  his 
movements  were  uncertain,  there  was  no  paralysis.  The  intracranial 
pressure  was  still  unaltered. 

The  fluid  remained  stationary  in  the  tube  of  the  instrument  till  sev- 
enteen minutes  had  elapsed.  Then  it  began  to  rise  slowly,  and,  with 
this  increase  in  the  intracranial  pressure,  paralysis  of  the  posterior  ex- 
tremities supervened.  As  the  amount  of  blood  contained  in  the  crani- 
um became  greater,  the  paralysis  extended,  the  pupils  dilated,  and  coma 
ensued.  The  return  to  sensibility  and  the  power  of  motion  was  attend- 
ed with  a  diminution  of  the  intracranial  pressure,  and  was  probably  di- 
rectly dependent  thereon. 

I  repeated  this  very  instructive  experiment  twice  with  similar  re- 
sults. 

The  deductions  to  be  made  from  them  are,  that  the  first  symptoms 
which  result  from  the  ingestion  of  alcohol  are  due  to  the  presence  of 
this  substance  in  the  brain,  while  the  latter  phenomena  are,  in  part  at 
least,  the  results  of  cerebral  congestion. 

Note. — In  these  and  other  experiments  detailed  in  this  chapter,  the  presence  of  alco- 
hol in  the  expired  air  was  determined  by  causing  the  breath  to  pass  through  a  solution  ol 
bichromate  of  potash  in  sulphuric  acid,  a  test  suggested  by  Masing,1  and  not  by  Lalle- 
mand,  Pcrrin,  and  Duroy,  as  generally  supposed. 

1  "De  mutationibus  spiritus  vini  in  corpus  ingesti,"  1854. 


ALCOHOLISM. 


909 


In  man  a  like  sequence  is  observed.  A  single  glass  of  wine  induces 
an  exhilaration  and  activity  of  mind  before  there  is  any  evidence  of  an 
increase  in  the  amount  of  blood  circulating.in  the  cerebral  blood-vessels. 
In  several  subjects  particularly  sensitive  to  the  action  of  alcohol,  I  have 
observed  that  the  flushing  of  the  face  and  increased  vascularity  of  the 
fundus  of  the  eye,  as  shown  by  the  ophthalmoscope,  were  second  in 
order  of  occurrence  to  others  indicating  mental  exc 

But,  as  is  well  known,  the  immediate  effects  of  a  large  quantity  of 
alcohol,  when  taken  into  the  human  stomach,  are  not  limited  to  mental 
excitement  and  Hushing  of  the  face.  It  does  not  come  within  the  scope 
of  this  chapter  to  consider  all  of  them  ;  but  so  far  as  the  nervous  sys- 
tem is  concerned  they  properly  come  under  notice. 

Levy1  divides  the  phenomena  of  alcoholic  intoxication,  as  they 
relate  to  the  nervous  system,  into  three  stages  :  excitement,  perturba- 
tion, and  destruction  of  the  functions  of  the  brain  and  spinal  cord. 
The  stage  of  excitement  is  characterized  by  .a  sensation  of  heat  in  the 
skin  of  the  whole  body  and  by  redness  of  the  face.  The  eyes 
to  be  larger  and  more  brilliant,  the  ideas  flow  more  readily,  the  ten- 
y  to  talk  is  generally  increased,  but  the  articulation  is  usually  not 
so  distinct  and  exact  as  is  natural.  The  disposition  becomes  more  gen- 
erous, and  perhaps  more  reckless  as  to  consequences,  although  the 
bounds  of  propriety  of  conduct  and  truth  of  expression  are  not  ex- 
ceeded. 

Occasionally  a  different  set  of  symptoms  results.     The  individual, 

i  being  naturally  talkative,  becomes  taciturn  and  stolid,  and  a  gen- 
erous disposition  is  changed  to  one  of  which  churlishness  and  selfish- 
ness are  the  chief  features. 

If  the  quantity  of  alcohol  taken  has  been  small,  or  if  the  individual 
now  to  drink  it,  the  subsequent  stages  do  not  supervene,  and 

the  equilibrium  is  soon  restored  without  the  occurrence  of  any  abnor- 
mal condition.     But,  if  the  amount  ingested  has  be  a  large,  oi  i 

ttions  are  continued,  the  second  stage,  thai  of  perturbs 

There  are  cow  vertigo,  disturbances  of  sighl — such  as  i 
paralysis  of  one  or  more  of  the  ocular  muscles,  and  gii  ing  rise  to  double 
□traction  of  the  pupils,  noises  in  the  ears,  and  u  red- 

of  i  he  face.    The  sen  kened,  i ! 

and  be  iugh  and  monotonous,  and  the 

articulation  is  indistinct  from  partial  pai  lina- 

tion  of  ( he  musclt  b. 

.  from  lik<  .  beoomei 

be  indh  idual  al  tempts  to  walk,  I 

alar,  an  I  .hil.it  m  mop  like 

■loluilirlit    ;i    t--.lt  UTO   Of   J 

the  J  '  he  brain  and 

1  "Traltf  iThyg 


910  TOXIC   DISEASES   CF   THE   NERVOUS  SYSTEM. 

Still  greater  alterations  from  the  normal  standard  are  shown  in 
the  mind  than  in  other  manifestations  of  nervous  action.  The  most 
striking1  change  occurs  with  the  emotions,  which  generally  assume  an 
undue  prominence  and  dominate  over  other  of  the  mental  faculties. 
And  it  not  infrequently  happens  that  the  feeling  which  is  most  conspic- 
uous is  the  very  opposite  of  that  which  is  natural  to  the  individual. 
Thus  the  brave  man  becomes  cowardly,  the  timid  courageous,  the  peace- 
able quarrelsome,  the  modest  shameless,  etc.  Usually,  however,  the 
emotions,  which  the  subject  in  his  normal  condition  is  able  to  control 
and  to  keep  in  proper  subordination  to  the  intellect  and  will,  become 
exaggerated,  and  are  no  longer  held  in  subjection.  It  therefore  hap- 
pens that,  when  this  stage  of  alcoholic  intoxication  is  reached,  the  indi- 
vidual, who  while  in  his  natural  state  is  high-toned  and  spirited,  is 
ready  to  take  offense  and  engage  in  quarrels  upon  the  slightest  provo- 
cation, and  often  when  no  cause  for  his  emotion  and  conduct  exists. 
It  is  in  this  stage  that  outrages  against  the  law  are  most  apt  to  occur. 

The  more  purely  intellectual  part  of  the  mind  does  not  escape.  The 
judgment  is  weakened,  the  memory  impaired,  the  imagination  exalted 
or  perverted,  and  delusions,  often  having  their  origin  in  disordered 
sensations,  and  often  arising  in  the  mind  without  any  accompanying 
illusion  or  hallucination,  may  assume  the  government  of  the  thoughts 
and  actions.  The  ability  to  grasp  the  details  of  a  subject,  and  to  com- 
prehend them,  is  greatly  injured,  or  even  altogether  destroyed,  and 
hence  study  or  continuous  and  systematic  thought  is  no  longer  pos- 
sible. 

In  the  third  stage  the  full  action  of  the  alcohol  is  attained.  The 
mental,  sensorial,  and  motor  functions  are  more  or  less  completely  abol- 
ished, and  death,  generally  the  direct  result  of  suspension  of  the  respir- 
atory movements,  may  ensue.  When  this  degree  of  alcoholic  intoxi- 
cation is  at  its  height,  the  individual  is  dead  to  all  external  impressions. 
Boiling  water  may  be  poured  on  his  body,  but  he  does  not  feel  it ; 
speech  is  impossible  ;  the  sphincters  are  relaxed,  allowing  the  contents 
of  the  bowels  and  bladder  to  escape  ;  the  pupils  are  largely  dilated  ; 
the  breathing  is  slow,  heavy,  and  often  stertorous  ;  the  face  is  swollen 
and  purple  from  the  circulation  of  non-oxygenized  blood  through  the 
vessels  ;  and  the  power  of  thought  is  extinct.  With  the  exception  of 
that  part  of  the  cerebro-spinal  axis  which  presides  over  the  functions 
of  respiration  and  circulation,  the  individual  is  to  all  appearance  dead. 
It  not  infrequently  happens  that  this  region  is  so  fully  affected  that 
life  is  abolished. 

Such  are  the  immediate  effects  of  large  quantities  of  alcohol  when 
ingested  into  the  human  stomach.  No  one  can  fail  to  observe  that 
most  of  the  remarkable  phenomena  which  follow  on  the  administration 
of  this  liquid  are  connected  directly  or  indirectly  with  the  nervous  sys- 
tem.    Tndeed,  experiments  performed  upon  animals,  with  reference  to 


ALCOHOLISM. 


911 


this  point,  as  well  as  careful  observation  of  the  effects  of  alcohol  on  the 
human  organism,  show  that  this  substance  has  a  signal  affinity  for  the 
nervous  tissue,  and  that  it  is  even  capable  of  acting  powerfully  on  the 
brain,  the  spinal  cord,  and  the  sympathetic  system,  without  the  inter- 
mediation of  the  blood.  Instances  are  on  record,  and  I  have  m 
witnessed  one  such,  in  which  a  large  quantity  of  alcoholic  liquor  taken 
into  the  stomach  has  produced  death  in  a  few  minutes  ;  and  Orfila  '  cites 
a  case  in  which  a  man  died  immediately  from  the  effects  of  an  excessive 
dose  of  brandy.  I  have  several,  times  killed  rabbits  in  less  than  a  min- 
ute by  introducing  an  ounce  of  pure  alcohol  into  the  stomach.  In  such 
cases  the  action  is  not  exerted  through  the  medium  of  the  blood,  but 
directly  on  the  sympathetic  system  or  medulla  oblongata  by  the  ter- 
minal nerve-branches  in  the  stomach.  Indeed,  if,  as  I  have  frequently 
done,  a  like  amount  of  alcohol  be  injected  into  the  blood  directly,  death 
does  not  ensue  with  so  great  a  degree  of  rapidity. 

Marcet a  says  : 

"  By  experimenting  on  frogs  I  have  shown,  in  a  paper  read  to  the 
British   Association,  in  1859,  that  a  sudden  temporary   suspension  of 
sensibility  or  shock   is  occasionally  brought  on  when  the  hind-legs  of 
these  animals  are  suddenly  immersed  in  strong  alcohol ;  and  I  have  ob- 
tained positive  proof  that  this  phenomenon  is  due  to  an  influenr 
erted  exclusively  on  the  extremities  of  the  nerves  supplying  those  li 
by  observing  this  same  effect  to  take  place  after  the  circulation  of  the 
parts  in   contact  with  alcohol  had  been  entirely  arrested.     "When,  on 
the  contrary,  the  nerves  of  the  limb  immersed  in  alcohol  were  severed 
from  their  centre,  the  circulation  being  left  undisturbed,  a  shock  never 
happened.     In  the  experiments  in  question  it  was  obvious  that  the  sud- 
den occurrence  of  insensibility  or  anaesthesia  was  due  to  an  action  of 
dcoholic  fluid  on  the  extremities  of  the  cerebro-spinal  nerves,  which 
action  had  been  transmitted  by  these  nerves  to  the  brain  ;  the  phenom- 
of  reflex  action  continued,  for  the  respiration  appeared  unimpaired, 
r  the  lapse  of  some  minutes  the  shock  passed  off  with  a  return 
■risibility,  although  the  frog's  hind-legs  had  ooi  b<  e  1  from 

the  alcohol." 

I  have  r  Marcet's  experiments,  with  every]  .-cau- 

tion to  guard  against  fallacy,  and  am  satisfied  thai  his  conclu 
riment  f  divided  all  the  tiaaw  s  of  both 
limbs  of  a  the  sciatic  nerves.     1  then  placed  small 

slips  of  thin  glass  and  ind  moistened  them  mth  a 

drop  •  imbibi- 

tion.    I  then  plunged  both  limbs  up  to  the  thighs  in  alcohol. 

i  in  eleven  seconds,  and  [a  I  >ur 

ing  its  continuance  the  animal  was  j 

'  "  Chronic  Alooholl  p,  n>.   • 


912  TOXIC   DISEASES   OF   TIIE   NERVOUS   SYSTEM. 

In  another  instance  I  performed  the  converse  experiment  of  exsect- 
ing  the  sciatic  nerves,  leaving  the  other  tissues  of  the  extremities  in- 
tact. I  then,  as  before,  inserted  both  legs  into  absolute  alcohol.  No 
bhock  ensued,  and  the  animal  was  not  apparently  affected  by  the  alco- 
hol till  twenty-two  minutes  had  elapsed. 

Absorption  of  alcohol  from  the  stomach  is  sometimes  greatly  de- 
layed, and  yet  many  of  the  effects  of  the  substance  are  observed.  Most 
of  us  have  seen  an  intoxicated  man  relieved  immediately  by  the  full 
action  of  an  emetic.  Of  course  the  emetic  in  such  a  case  can  only 
remove  the  non-absorbed  alcohol  still  remaining  in  the  stomach,  and 
yet  the  symptoms  of  inebriation  disappear  on  its  ejection.  It  can  only 
have  acted  through  the  nervous  system,  without  the  intermediation  of 
the  blood. 

Observations  and  experiments  such  as  these  are  very  striking  and 
important.  They  tend  to  show  that  the  action  of  alcohol  is  exerted 
upon  the  nervous  system  in  a  twofold  manner,  and  they  are  evidence 
of  the  remarkable  affinity  which  the  substance  in  question  has  for  the 
nerve-tissue. 

Post-mortem  examinations  of  persons  who  have  died  directly  from 
the  effects  of  alcohol,  or  who  were  during  life  habitual  drunkards,  also 
show  how  powerfully  the  nerve-centres  ai*e  influenced  by  this  agent. 
In  extreme  cases  it  has  not  infrequently  happened  that  the  brain,  on 
being  exposed,  has  evolved  a  strong  odor  of  alcohol.  It  is  true  that 
the  experiments  of  Dr.  Hutson  Ford 1  appear  to  show  that  alcohol  is  a 
normal  constituent  of  the  blood  ;  but  it  is  very  certain  that  the  quan- 
tity is  altogether  too  small  to  give  the  characteristic  odor  of  this  sub- 
stance, although  the  reaction  with  chromic  acid,  and  the  distillate  being 
capable  of  ignition  and  burning  like  alcohol,  are  affirmative  evidences 
of  great  significance.  He  did  not,  however,  examine  the  brain  for  alco- 
hol, and  my  own  experiments  on  this  point,  with  the  brains  of  dogs  and 
oxen,  and  of  men  not  addicted  to  the  use  of  alcoholic  liquors,  have 
given  negative  results.  Aware,  however,  of  the  great  affinity  which 
the  cerebral  and  other  nerve-tissues  have  for  alcohol,  it  seems  to  me 
that  if  this  substance  is  normally  present  in  the  blood  it  ought  to  be 
found  as  well  in  the  brain  as  in  the  lungs  and  liver,  unless,  as  may  have 
been  the  case,  the  alcohol  discovered  by  Dr.  Ford  in  these  organs  and 
in  the  blood  was  a  post-mortem  production. 

With  the  view  of  still  further  elucidating  this  subject,  I  fed  a  rabbit 
largely  every  day  with  bread  soaked  in  whiskey.  In  the  course  of  that 
time  the  animal  received  nearly  a  pint  of  the  liquor,  but  beyond  being 
somewhat  stupefied  it  did  not  appear  to  be  seriously  inconvenienced. 
At  the  end  of  ten  days  the  animal  was  killed. 

I  then  removed  the  brain,  the  spinal  cord,  and  all  the  large  nerves, 

1  "Normal  Presence  of  Alcohol  in  the  Blood,"  Journal  of  the  Elliott  Society  oj 
Natural  History,  vol.  i.,  Charleston,  1859. 


ALCOnOLISiL  913 

and  treated  them  separately  with  distilled  water  after  cutting  them 
into  small  pieces.  They  were  then  thrown  upon  a  filter  and  strongl) 
pressed. 

The  three  separate  portions  of  liquid  extract  were  then  distilled 
several  times,  and  finally  treated  with  quicklime  and  again  distilled. 
The  odor  of  the  distillates  was  almost  sufficient  of  itself  to  establish 
the  presence  of  alcohol,  but,  when  the  vapor  from  each  was  pa- 
through  the  solution  of  bichromate  of  potash  in  sulphuric  acid  the 
characteristic  green  color  resulting  from  the  action  of  alcohol  was  at 
once  produced. 

So  far  as  I  am  aware,  no  previous  experiments  had  established  t lie 
existence  of  alcohol  in  the  spinal  cord  and  the  nei 

A  portion  of  the  blood  of  the  same  animal  treated  in  like  manner 
failed  to  exhibit  evidence  of  the  presence  of  alcohol.  The  experiments, 
therefore,  showed  that  the  nervous  tissue  had  a  greater  affinity  for  this 
substance  than  the  blood.' 

Besides  the  moibid  conditions  which  exist  in  the  nervous  syst-  m  a> 
the  direct  result  of  the  ingestion  of  alcohol  in  large  quantities,  this  sub- 
stance is  capable  of  causing  other  patho-anatomical  states  which  bays 
already  been  described  in  this  treatise. 

Treatment. — In  the  first  place,  in  the  treatment  of  chronic  alcohol- 
ism, the  physician  should  insist  upon  entire  cessation  from  the  use  of 
alcoholic  liquors.  It  usually  happens  that  the  bowels  are  deranged  by 
constipation  or  diarrhoea.  In  either  ease  a  mild  purgative  will  be  found 
of  service.  I  know  of  nothing  better  than  the  following':  K.  Aloes, 
ext.  fel.  bovis  exsic,  &8  grs.  xv  ;  resinsB  podophilli,  grs.  ij.  M.  ft.  in 
pill  no.  v.     Dose,  one  every  alternate  day. 

For  the  special  treatment  of  the  com1  it  ion  the  oxide  of  zino  in 
of  two  or  three  grains  three  times  s  day  has  been  strongly  recom- 
mended by  Marcet,  and  is  certainly  possessed  of  great  power  in  this 
direction.  Under  its  use  the  symptoms  soon  begin  to  disappear,  and 
the  patient  to  resume  his  normal  condition  of  mind  and  body.  Hut  in 
my  experience  it  is  far  inferior  to  the  bromides  of  potsssiuin,  sodium, 
calcium,  or  ammonium,  which,  when  given  in  doses  of  from  fifteen  to 
thirty  grains  in  solution  three  times  a  day,  are  exceedingly  efficacious. 
Even  they,  however,  are  inferior  t'-  the  bromide  of  xino,  whioh  mej 
administered  in  the  dose  of  two  grains  in  solution  in  wa1  npk 

syrup  three  or  four  times  a  daj     gradually  incn  ths 

stomach  will  permit,  to  two  or  three  times  thai  quantity. 

peoially  in  those  in  whioh  insomnia  is  i  prominent 

feature,  the    /in. mpOUnd    mav   be    advaul  i   with    either 

of  the  other  bromides  mentioned. 

1  These  experiment!  vers  performed  before  ti 
4,  1871,  tod  ere  del  i  fth  la  the 

July,  LI 

Bfl 


914  TOXIC  DISEASES  OF  THE  NERVOUS  SYSTEM. 

I  am  very  sure  that  in  digitalis  we  have  an  important  adjunct  to  the 
treatment  mentioned.  It  not  only  acts  as  a  tonic  to  the  heart,  but  it 
is  the  most  active  agent  we  possess  as  an  eliminant  of  alcohol  through 
the  kidneys.  I  prefer  the  infusion  in  doses  of  a  tablespoonful  three 
or  four  times  a  day.  The  tincture  may  be  given  in  doses  of  from  fif- 
teen to  thirty  drops,  as  often. 

In  acute  alcoholism,  or  delirium  tremens,  the  treatment  depends 
very  much  upon  the  mode  of  origin  of  the  disease. 

In  those  cases  which  have  resulted  from  the  sudden  cessation  from 
the  use  of  alcoholic  liquors,  opium  with  brandy  or  whiskey  should  be 
given.  The  main  indication  is  to  procure  sleep  as  soon  as  possible,  and 
I  am  aware  of  no  means  so  effectual  in  cases  of  this  kind  as  the 
hypodermic  injection  of  large  doses  of  morphia — one-fourth  to  half  a 
grain — as  often  as  may  be  required,  combined  with  the  internal  admin- 
istration of  brandy  or  whiskey  in  moderate  quantities. 

When,  however,  the  affection  has  come  on  during  a  debauch,  noth- 
ing can  be  much  worse  than  either  of  those  substances.  They  add  fuel 
to  the  flame.  In  such  cases  the  bromides,  in  large  doses,  combined  with 
digitalis,  are  the  most  effective  remedies.  A  drachm  of  the  bromide  of 
potassium,  for  instance,  may  be  given  in  solution  in  a  tablespoonful  of 
infusion  of  digitalis  every  hour  or  two,  and  it  will  generally  happen 
that  sleep  will  follow,  with  the  cessation  or  mitigation  of  all  the  perma- 
nent symptoms. 

The  hydrate  of  chloral  has  been  recommended  in  delirium  tremens, 
but  I  have  no  personal  experience  of  its  use. 

The  monobromide  of  camphor  has  been  used  successfully  in  delir- 
ium by  M.  Seneffe,  of  Belgium,  and  by  Dr.  O'Hara,  of  this  country.  I 
have  also  recently  employed  it  in  one  case — administering  four  grains 
in  capsule  every  hour.  After  the  eighth  dose  the  patient  slept  four 
hours.  The  remedy  was  again  given  as  before,  and  after  six  doses 
another  period  of  sleep,  this  time  of  six  hours'  duration,  was  obtained. 
The  further  administration  was  not  necessary. 

With  the  medical  treatment  in  either  form  of  delirium  tremens  the 
strength  should  be  supported  with  beef-tea,  and,  after  convalescence, 
quinine,  iron,  and  strychnia,  will  prove  of  service. 


BROMISM.  91{j 

CHAPTER  III. 

BBOMZSM. 

Is  view  of  the  facts  that  the  bromides  of  potassium,  sodium,  calcium, 
lithium,  and  ammonium,  are  necessarily  administered  in  several  diseases 
of  the  nervous  system,  notably  in  epilepsy,  in  large  doses  and  for  long 
periods,  and  that  a  peculiar  condition  is  thereby  induced,  it  is  impor- 
tant that  the  resultant  phenomena  should  be  recognized. 

In  adults  it  is  rarely  the  case  that  any  decided  symptoms  of  bromism 
are  caused  by  doses  of  less  than  thirty  grains  daily,  and  not  often  that 
forty-five  grains  a  day  produce  them  in  any  great  intensity.  In  chil- 
dren, however,  and  sometimes  in  weak  individuals,  smaller  quantities 
will  give  rise  to  very  well-marked  phenomena. 

Symptoms. — The  first  symptom  to  make  its  appearance  in  cases  of 
bromism  is  drowsiness.  The  patient  sleeps  not  only  at  night,  but  in 
the  day,  and  often  under  circumstances  in  which  sleep  would  appear  to 
be  almost  out  of  the  question.  Feebleness  of  the  arms  and  legs,  espe- 
cially of  the  latter,  is  generally  the  next  sign.  The  gait  becomes  titu- 
bating, and  falls  are  apt  to  occur,  especially  in  children.  The  grasp 
of  the  hands  is  weak,  and  there  appears  to  be  an  anaesthesia  of  what 
may  be  called  the  muscular  sense,  for  articles  held  are  dropped  tu 
the  sight  be  kept  upon  them. 

Articulation  is  very  early  interfered  with,  so  that  the  speech  be 
thick  and  indistinct.    "Words  are  omitted  and  others  are  clipped  <>f  their 
final  syllables,  or  are  slurred  over  in  a  tangled  mass  of  incomprehensiUe 
utterances. 

The  action  of  the  heart  is  weakened,  and  at  the  same  time  rendered 
more  frequent;  the  skin  is  cold  and  clammy,  the  countenance  is  pale, 
and  the  pupils,  from  being  at  first  somewhat  contracted,  become  widely 
dilated  and  somewhat  insensible  to  light. 

The  I  is  reddened,  thickly  ooated,  dry,  and  sometimes 

The  breath  has  the  odor  of  bromine  or  is  otherwise  offensive  :  the  I 
els  arc  usually  constipated,  and  the  urine  is  ordinarily  increased  in  quan- 
tity. 

The  skin,  even  in  oases  in  whioh  the  other  symptoms  of  bromism 
are  not  very  evident,  is  the  seat  of  numerous  pustuli  tally  thai 

covering  the  face,  neck,  baok,  and  chest,  and  occasionally  Is  or 

carbuncles  make  their  appearanoe, 

The  fane.  n  intensely  c  '.  and  aphthous  patches  ap 

on  the  mucous  membrai f  1 1 » .  -  buccal  oavity.    The  respiration 

becomes  burri  !,  and  bronohitifl  ition 

of  f  lie  lungs  may  i  i 

The  b<  risibility  of  the  pharynx  is  markedly  impaired,  and  its  i 
excitability  is  almost   if  col  entirely  al  L     It  requires  a  mental 


916  TOXIC   DISEASES   OF  THE   NERVOUS   SYSTEM. 

effort  for  the  patient  to  swallow,  and  manual  irritation  of  the  fauces 
fails  to  excite  nausea  or  efforts  to  vomit. 

Finally,  locomotion  becomes  impossible,  the  patient  is  in  a  state  of 
continual  stupor,  incapable  of  making  known  his  wants — in  fact,  hav- 
ing no  wants — and  unable  to  recognize  those  about  him  ;  the  urine  and 
fasces  are  passed  involuntarily,  the  lungs  are  engorged,  the  heart  be- 
comes still  weaker,  and  if  the  administration  of  the  bromide  be  not  sus- 
pended death  ensues. 

In  a  paper  which  I  published  l  several  years  ago,  I  called  attention 
to  this  remarkable  condition,  and  adduced  several  cases  in  illustration 
of  the  points  then  brought  forward.  They  were  noticed  by  Huette  * 
many  years  ago,  though  not  very  perfectly.  He  was  the  first  to  ob- 
serve the  effects  of  bromide  of  potassium  upon  the  generative  function 
in  the  abolition  it  causes  of  sexual  desire  and  power. 

Before  the  extreme  influence  of  the  bromides  is  attained,  a  patient 
under  their  influence  presents  phenomena  very  similar  to  those  exhibit- 
ed by  a  drunken  person.  A  case  which  formed  one  of  the  series  given 
in  the  paper  referred  to  is  so  apposite  in  the  present  connection  that  1 
cite  it  here  : 

A  gentleman  consulted  me  in  January,  1867,  for  severe  headache, 
with  which  he  had  suffered  for  many  years.  He  informed  me  that  he 
had  once  fallen  from  the  rigging  of  a  vessel,  had  struck  his  head,  and 
was  rendered  insensible  for  several  hours.  Subsequently  he  had  a  sun- 
stroke in  Texas.  I  considered  this  a  suitable  case  for  the  administra- 
tion of  the  bromide  of  potassium,  and  accordingly  prescribed  for  him  a 
teaspoonful  three  times  a  day  of  a  solution  containing  one  ounce  of  the 
medicine  to  four  ounces  of  water.  He  thus  took  about  fifteen  grains 
at  a  dose.  The  effects  of  this  were  so  pleasant  to  him,  and  yet  not  alto- 
gether so  strong  as  he  desired,  that  he  began  to  increase  the  dose.  Be- 
ing absent  from  the  city  for  two  or  three  weeks  at  that  time,  I  did  not 
witness  the  phenomena.  I  was  informed,  however,  that  he  had  exhib- 
ited symptoms  of  mental  aberration.  These  wore  off  on  the  cessation 
of  the  medicine,  and  when  I  returned  he  was  comparatively  well. 

His  headaches,  however,  soon  came  back  with  all  their  original  vio- 
lence, and  at  his  earnest  solicitation,  and  under  his  promise  not  to  ex- 
ceed the  prescribed  dose,  I  again  gave  him  the  bromide.  He  very  soon 
began  to  increase  the  quantity,  and  finally  seemed  to  have  lost  all  con- 
trol of  his  appetite  for  it.  At  this  time  I  ascertained  that  be  was  in  the 
habit  of  having  his  four-ounce  vial  containing  an  ounce  of  the  bromide 
filled  every  day.  The  first  obvious  effect  was  an  unsteadiness  of  gait. 
So  great  was  this  that  he  was  frequently  taken  for  a  drunken  man,  and 
on  one  occasion  was  arrested  by  the  police,  confined  in  a  cell  all  night, 

1  •'  On  some  of  the  Effects  of  the  Bromide  of  Potassium  when  administered  in  Large 
Doses,"  Quarter!)/  Journal  of  Psychological  Medicine,  vol.  iii.,  1809,  p.  46. 
e  Gazette  Medicale,  June,  1850. 


BROMISM.  917 

and  fined  the  next  morning,  notwithstanding  my  statement  of  the  facts 
to  the  police  superintendent.  On  another  occasion  I  met  him  in  the 
street,  as  I  was  going  to  visit  him.  He  was  now  decidedly  insane  ; 
had  delusions  that  lewd  women  had  got  into  his  mother's  house  ;  that 
he  was  pursued  by  the  police  ;  that  his  life  was  threatened  by  members 
of  the  family  ;  that  he  had  thousands  of  dollars  of  gold  sewed  up  in  his 
clothing,  etc.  When  I  met  him  his  appearance  and  manner  were  very 
similar  to  those  of  a  drunken  man,  except  that  his  face  was  exceedingly 
pale.  This  gentleman  was  a  total-abstinence  man  as  regarded  intoxi- 
cating liquors  of  all  kinds.  His  manner  was  excited  and  rambling,  and 
his  hands  were  constantly  busy  either  m  fumbling  in  his  pockets,  tying 
his  shoes,  picking  threads  from  his  clothing,  or  in  reaching  for  the  gold 
which  he  believed  was  concealed  in  the  lining  of  his  coat.  His  charac- 
ter had  also  undergone  a  radical  change.  From  having  been  very  frank 
and  brave,  he  had  become  excessively  timid  and  suspicious  of  every 
trifling  circumstance. 

Up  to  this  period  I  was  not  quite  sure  that  he  was  suffering  from 
the  effects  of  bromide  of  potassium.  His  symptoms  were  in  many  re- 
spects so  much  like  those  of  an  ordinary  attack  of  acute  mania,  and  his 
antecedents  were  of  such  a  character  as  to  predispose  him  to  an  acces- 
sion of  the  kind,  that  I  had  reasons  for  my  doubts.  Nevertheless,  I  en- 
deavored  to  stop  his  use  of  the  bromide.  This  was  a  difficult  task,  for, 
notwithstanding  all  efforts,  he  continued  to  get  hold  of  it.  At  last  it 
was  ascertained  that  he  had  secreted  large  quantities  of  it  in  various 
out-of-the-way  places  about  the  house. 

His  mental  derangement  had  now  become  so  prominent  and  con- 
stant that  his  friends  became  alarmed  for  his  own  and  their  safety.  He 
had  several  times  attempted  to  throw  himself  from  the  window,  and  had 
battered  down  a  door  with  an  axe  in  order  to  escape  from  some  imagi- 
nary danger.  I  fader  these  circumstances  I  recommended  his  committal 
to  a  lunatic  asylum,  and  he  was  accordingly  removed  to  Sanford  Hall, 
a(  Blushing.  Here  his  symptoms  gradually  disappeared,  and  in  a  month 
he  returned  to  his  home  well.  He  has  continued  so  to  this  day,  with 
the  exception  that  his  headaches,  which  had  disappeared  while  ho  was 
under  the  influence  of  the  bromide,  became  as  Bevere  as  ;it  first,  and 
siill  continue. 

This  was  certainly  an  extrei >ase,  bul  others  fully  as  well  marked 

bave  come  under  my  no1  ice. 

The  effects  due  f<>  the  continued  administration  of  the  bromide  of 
potassium  bave  col  been  more  clearly,  fully,  and  al  the  Bame  time 
succinctly  stated  than  by  Dr.  K.  II.  Clarke.1     Be  says: 

"The  principal  phenomena  following  the  oontinued  dose  are:  aone; 

1  "Ti.    I'  ind  rhenpeotio&l  action  of  the  Bromide  of  Potassium  tad  Bru 

mlde  of  ammonium,"  by  Edward  II.  Clarke,  M.l>.,  and  Robert  Amory,  M  i>..  Boston 

872,  p 

00 


918  TOXIC   DISEASES   OF  THE   NERVOUS  SYSTEM. 

salivation  and  salt  taste  in  the  mouth;  irritation  of  the  fauces,  generally 
with  oedema  and  redness,  and  sometimes  with  paleness  of  those  parts; 
moderate  anaesthesia  of  the  pharynx;  laryngo-bronckial  weakness,  some- 
times with  cough  and  sometimes  with  a  changed  or  whispered  voice, 
rarely  with  aphonia;  a  fetid  or  bromized  breath;  occasional  stammer- 
ing; increase  of  renal  secretion;  diminution  of  mucous  secretion  gen- 
erally; slight  constipation,  and,  in  a  few  rare  cases,  diarrhoea;  sense 
of  mental  and  physical  languor  or  weakness;  sometimes  temporary 
impairment  of  the  memory,  general  aspect  of  hebetude  or  indifference; 
more  or  less  somnolence;  repression,  and  occasionally  temporary  aboli- 
tion of  sexual  desire  and  power;  impaired  locomotion,  which,  when  the 
dose  is  excessive,  resembles  the  gait  of  locomotor  ataxia;  diminished 
nervous  sensibility  in  general,  and  especially  diminution  of  reflex  sensi- 
bility; and,  finally,  an  increase  of  destructive  without  a  corresponding 
increase  of  constructive  metamorphosis,  and  consequent  emaciation." 

When  administered  in  larger  quantities  than  are  just  sufficient  to 
produce  the  foregoing  symptoms,  the  phenomena,  as  detailed  by  Dr. 
Clarke,  are: 

"The  fetid  breath  becomes  nauseous;  oedema  supervenes  on  conges- 
tion of  the  uvula  and  fauces;  the  whispering  voice  sinks  into  aphonia; 
sexual  weakness  degenerates  into  impotence;  muscular  weakness  be- 
comes complete  paralysis;  reflex,  general,  and  special  sensations  dis- 
appear; the  ears  do  not  hear,  or  the  eyes  see,  or  the  tongue  taste;  the 
expression  of  hebetude  becomes  first  that  of  imbecility,  and  then  that  of 
idiocy;  hallucinations  of  sight  and  sound,  with  or  without  mania,  pre- 
cede general  cerebral  indifference,  apathy,  and  paralysis;  the  respira- 
tion, without  the  stertor  of  opium  or  alcohol,  is  easy  but  slow;  the  tem- 
perature of  the  body  is  lowered;  as  the  bromism  becomes  more  pro- 
found, the  patient  lies  quietly  in  his  bed,  unable  to  move,  or  to  feel,  or 
swallow  or  speak,  with  dilated  and  uncontractile  pupils,  and  scarcely 
any  change  of  the  color  of  the  skin  or  face;  the  extremities  grow 
gradually  colder  and  colder;  the  action  of  the  heart  becomes  feeble 
and  slower,  till  it  ceases  altogether." 

Dr.  Clarke  reports  one  death,  in  which  this  result  was  probably  due 
to  bromism.  Three  have  come  under  my  observation,  in  which  bromism 
was  probably  instrumental  in  hastening  a  fatal  termination.  In  one  of 
these  the  patient,  a  .young  lady,  was  the  subject  of  epilepsy.  She 
resided  out  of  the  city,  and  I  prescribed  the  bromide  of  potassium  in 
doses  of  fifteen  grains  three  times  a  day.  While  taking  it,  and  fully 
under  its  influence,  she  contracted  pneumonia  ;  but,  without  my  knowl- 
edge, the  medicine  was  continued,  and  she  died. 

The  second  case  was  that  of  a  lady  forty  years  of  age,  also  subject 
to  epilepsy,  for  whom  I  prescribed  the  bromide  of  sodium  in  doses  of 
fifteen  grains  three  times  a  day.  The  bromic  cachexia  soon  became 
strongly  marked,  but,  as  I  saw  her  every  day,  I  did  not  think  it  advis- 


BR0MI8M. 

able  to  reduce  tlie  doses.     She  went  out  every  day,  and  on  one  o 
sion  crossed  the  North  River  ferry  to  meet  some  friends.     She  caught 
a  severe  cold,  pneumonia  supervened,  and,  though  the  admin- 
of  the  medicine  was  at  once  stopped,  she  died  in  the  second  stage  of 
the  disease. 

In  both  these  cases  the  bromide  probably  w;is  indirectly  the 
of  death  by  the  asthenia  which  it  produced. 

In  the  third  case  the  patient,  a  lady  from  .  .  epi- 

leptic, visited  New  York  to  consult  me  relative  to  her  rtmosno  I 
scribed  for  her  as  in  the  last-named  case,  and,  after  remaininj 
night  in  the  city,  she  returned  home  with  no  great  degree  "t"  br  imism. 
But,  after  her  departure,  the  toxic  influence  became  more  strongly 
marked,  and,  before  I  could  be  written  to  and  my  answer  obtained,  the 
medicine  being  continued  all  the  time,  death  occurred.  In  this  instance 
the  result  was  doubtless  entirely  due  to  bromism. 

Causes. — For  the  production  of  bromism,  more  ox   Less  proli 
administration  of  a  bromide — the  continued  dose  of   I  )r.   Clarke — is 
necessary.     In  my  experience  the  potassium  and  sodium  suits  equally 
cause  it;  the  lithium,  calcium,  and  ammonium  compounds,  lily; 

the  bromide  of  zinc  not  at  all;  but  this  result  may  be  due  to  the  tad 
that  this  preparation  is  not  administered  in  as  l.n 
Great  differences  exist  among  individuals  in  regard  t<>  the  ca] 
be  brought  under  the  full  influence  of  a  bromide;  but    I  kno*  of    no 
signs  by  which  these  differences  can  be  previously  ascertained,  63 
those  of  age  and  sex;  children  and  women  being  in": 
as  a  rule. 

The  administration  of  a  bromide  in  a  largely  diluted  form  facilitates 
the   action  of  the  drug  on  the  system,  and  consequently  leads  more 
readily  to  the  promotion  of  bromism.     This  is  probably  due  to  the 
of  its  greater  endosmotic  power,  and  consequent  more  rapid  absorption 
into  the  blood. 

The  Diagnosis  of  bromism  scarcely  rails  for  remark.    The  proi:  I 
is  almost  invariably  favorable  if  the  administration  of  the  drug  be 
Btopped  when  the  phenomena  become  profound  and  tl 
superadded  affections  present. 

Of  the  Morbid  Anatomy  nothing  is  known,  and  the  Patholog 
therefore,  based  entirely  on  what  bas  been  ascertained  relative  to  the 
iological  and  therapeutic  action  of  the  bromio  compounds.     Chief 
mi"'  are  the  facts  that  it  diminishes  the  amount  of  bl< 

lating  in  the  cerebral  blood-vessels,  and  that  it 
of  the  whole  oerebro-spinal  and  sympathetic  I 

effects  wen-  set  forth  in  a  paper1  published  more  than  t 
and  have-been  generally  oonfiri 

1  "On  Bleep  an  t  In 


920  TOXIC   DISEASES  OF  THE   NERVOUS  SYSTEM. 

self  in  various  memoirs.1  Relative  to  the  influence  which  the  bromides 
exert  in  diminishing  the  quantity  of  blood  in  the  brain,  the  fact  admits 
of  actual  demonstration  by  means  of  inspection  through  the  trephined 
skulls  of  animals  and  by  the  use  of  the  cephalohaemometer  described 
in  the  introduction  to  this  work. 

Many  of  the  most  striking  phenomena  of  bromism  are  the  result  of 
the  cerebral  anaemia  which  the  bromides  produce.  The  paleness  of  the 
countenance,  the  dilatation  of  the  pupils,  the  mental  and  physical  weak- 
ness, the  somnolence,  the  cardiac  debility,  all  result  from  the  intra- 
cranial condition. 

Among  the  secondary  effects  are  those  cited  by  Bartholow  : a  the 
retardation  of  the  process  of  destructive  metamorphosis,  the  diminution 
of  the  sexual  desire  and  power,  and  gastric  derangement. 

M.  Laborde  3  has  performed  a  number  of  experiments  on  man  and 
other  animals  with  the  bromide  of  potassium.  Four  or  five  minutes 
after  the  administration  of  from  three  to  six  grains  to  frogs,  a  slight 
general  excitement,  with  moderate  tetanic  movements,  was  produced. 
Weakness  followed,  and  then  there  was  a  condition  of  flaccidity,  during 
which  reflex  action  was  entirely  abolished.  The  heart  was  but  slightly 
affected,  and  continued  to  contract  for  several  hours  after  this  loss  of 
reflex  power.  Laborde  concludes,  therefore,  that  bromide  of  potassium 
has  no  special  action  on  the  heart,  muscles,  encephalon,  or  nerves,  but 
that  it  mainly  and  primarily  injures  the  spinal  cord. 

These  views  are  doubtless  true  as  regards  the  frog,  in  which  animal 
the  spinal  cord  is  mainly  the  seat  of  the  mind,  and  therefore  any  cere- 
bral influence  must  be  very  slightly  manifested  ;  but  they  certainly  are 
not  correct  so  far  as  man  and  the  superior  animals  are  concerned. 

Other  observers  have  written  relative  to  the  physiological  effects  of 
the  bromides,  among  whom  MM.  Damourette  and  Pelvet 4  may  be  men- 
tioned. 

In  the  work  of  Drs.  Clarke  and  Amory,  to  which  reference  has  al- 
ready been  made,  Dr.  Amory  enunciates,  among  other  propositions,  the 
following  : 

"  The  loss  of  reflex  action  is  due  to  the  diminution  of  blood  in  the 
periphery  of  the  nerves  and  also  of  the  central  nervous  system,  this  last 
occurring  after  the  first. 

"  The  action  of  bromide  of  potassium  on  the  nervous  system  may  bo 
explained  by  its  action  on  the  capillary,  arterial,  or  central  circulation." 

These  propositions  are  supported  by  various  experiments,  and  ap- 
pear to  be  well  established. 

1  "  On  some  of  the  Effects  of  the  Bromide  of  Potassium,"  etc.,  Quarterly  Journal  oj 
Psychological  Medicine,  January,  1869. 
3  Cincinnati  Lancet  and  Observer,  1865. 

3  Comptcs  Iiendu-t,  July  8,  1868. 

4  Bulletin  rjenerale  de  iherapcutique,  1867,  pp.  241,  289. 


ITYDRARGYSM. 


921 


The  recent  work  of  Voisin  '  adds  nothing  to  our  previous  knou 
of  the  subject. 

Treatment. — There  is  no  special  treatment  for  bromism  beyond  that 
which  consists  in  suspending  at  once  the  administration  of  the  medi- 
cine, facilitating  its  elimination  from  the  system,  and  sustaining  the 
strength.     Dr.  Clarke"  has  shown  that  the  faeces  do  not  contain  an  ap- 
preciable quantity  of  the  bromide  of  potassium,  even  when  it  is  1 
taken  in  large  quantity.     He  found  that  it  is  mainly  eliminated  by  tin- 
kidneys  and  by  the  skin.     It  is  difficult  to  avoid  the  opinion,  in  view  of 
the  odor  of  the  breath  of  persons  taking  a  bromide,  that  bromin 
eliminated  with  the  expired  air,  but  !  fer.  <  larke's  experiments  appear  t 
establish  the  negative.     The  indication,  therefore,  is  to  administer  diu- 
retics and  diaphoretics.     Nothing  is  better  for  the  first  than  digit 
which  not  only  acts  upon  the  kidneys,  but  is  also  a  tonic  to  the  heart, 
and  for  the  latter  than  warm  drinks,  such  as  infusion  of  flaxseed,  lemon- 
ade, etc.,  which  are  also  more  or  less  diuretic. 

The  strength  of  the  patient  should  be  sustained  with  brandy  or  wine, 
quinine,  beef-tea,  etc. 


CHAPTER     IV. 

UYDRAROYSX. 

Symptoms. — The  consequences  to  the  nervous  system,  from  the  alow 
absorption  of  mercury  into  the  organism,  have  been  Known  Cor  many 
years.     The  principal  phenomenon  witnessed  is  tremor,  but  then 
other  svmptoms  which  serve  for  the  recognition  of  the  nature  of 
disorder. 

Thus  the  gums  are  swollen  ami  tender,  the  breath  fetid,  the 
become  loose,  especially  those  of  the  lower  jaw,  and  there  is  -i  metallic 
taste  in  the  mouth.     The  lining  membrane  of  the  mouth  and  throal 
comes  inflamed,  and  ulcerations  very  generally  occur  in  the  faui 
quantity  of  saliva  is  greatly  increased. 

These  symptoms  exist  mainly  in  the  firsl  stage  of  bydrai 
constitute  wliaf  is  generally  called  salivation.     But,  if  the  men 
tinues  to  be  taken  into  the  Bystem,  another  series  of  phenomeo 
pears.     Or,  if  the  absorption   lias  been  extremely  i 
may  be  in  greal  part,  or  entirely,  absent. 

The  symptoms  referred  to  are  paleness  or  lividity  of  the  counte- 
nance, the    Erequenf    occurrence  <>f   nasal   haemorrhages,  and 
mental  weakness.     The  physioal  strength  gradually 
tremor  makes  ita  appearance,  mostly  confined,  in  i1 

»  "Do  I'emplof  de  bromon 
»  Op.  at.,  p.  II 


922  TOXIC   DISEASES   OF   THE   NERVOUS  SYSTEM. 

least,  to  the  superior  extremities  and  the  head.  Finally,  the  lower 
limbs  are  affected,  and,  in  addition,  are  generally  the  seat  of  oedema. 
Pains  in  the  bones,  and  caries,  and  necrosis,  especially  of  the  maxillary 
bones,  may  occur  together  with  ulcerations  of  the  soft  parts. 

The  mental  symptoms  are  generally  strongly  marked.  There  are 
hallucinations  and  delusions,  accompanied  sometimes  with  a  high  de- 
gree of  maniacal  excitement.  Epileptiform  convulsions  may  occur,  as 
may  also  paralysis  of  various  parts  of  the  body,  and  finally,  unless  re- 
lief be  afforded,  death  ensues. 

Causes. — Mercury  may  be  taken  into  the  system  and  be  the  cause  of 
slow  poisoning,  through  the  skin,  the  stomach  and  intestines,  and  the 
lungs.  Fire-gilders,  looking-glass  manufacturers,  barometer-makers, 
the  workers  in  quicksilver-mines,  bronzers,  the  makers  of  artificial  flow- 
ers, and  photographers,  exposed  as  they  are  to  the  vapor,  the  fine  pow- 
der, or  a  solution  containing  mercury,  are  therefore  liable  to  its  toxic 
influence.  Hydrargysm  has  also  been  known  to  be  induced  by  the  long- 
continued  administration  of  preparations  of  mercury  in  medical  prac- 
tice, and  even  from  the  filling  of  a  tooth  with  an  amalgam. 

I  have  known  of  a  case  of  mercurial  tremor,  produced  in  a  young 
lady  by  the  use  of  a  solution  of  corrosive  sublimate  as  a  cosmetic  to 
remove  pimples  from  the  face. 

The  Diagnosis  of  hydrargysm  is  in  general  much  elucidated  by  the 
clinical  history  of  the  case  and  the  knowledge  that  the  patient  has  been 
exposed  to  mercurial  emanations.  In  addition,  the  tremor,  the  fetid 
breath,  loosening  of  the  teeth,  caries  of  the  bones,  and  the  muscular 
weakness,  are  diagnostic  signs  of  value,  while  the  absence  of  the  blue 
line  on  the  gums — although  it  is  stated  that  such  a  line  is  sometimes 
present — and  the  fact  that  the  extensors  are  not  especially  the  seat  of 
paralysis  will  suffice  for  the  discrimination  of  hydrargysm  from  plumb- 
ism . 

But  the  diagnosis  is  rendered  quite  certain  by  the  administration  of 
the  iodide  of  potassium,  which,  as  Melsens  has  shown,  separates  mer- 
cury from  its  combinations  with  the  tissues  of  the  body,  forming  with  it 
a  new  compound — the  iodide  of  mercury — which  is  eliminated  with  the 
urine.  All  that  is  necessarj',  therefore,  is  to  give  the  iodide  of  potassi- 
um in  large  doses  to  a  patient  suspected  to  be  suffering  from  hydrar- 
gysm, to  put  a  few  drops  of  the  urine,  excreted  during  the  second  day, 
on  a  bright  copper  plate,  and  then  add  a  drop  of  hydrochloric  acid. 
A  blight  metallic  stain  will  be  found  on  the  plate  if  mercury  be  present. 
The  iodide  of  mercury  is  decomposed  and  the  metal  is  precipitated  as 
stated. 

The  Prognosis  is  generally  favorable  if  the  patient  can  be  removed 
from  further  contamination  with  mercury  and  be  subjected  to  proper 
treatment. 

Morbid  Anatomy  and  Pathology. — There  are  no  data  by  which  we 


ARSEXICISM. 

can  form  an  opinion  relative  to  the  anatomical  changes  induced  in  the 
nerve-tissues  by  the  action  of  mercury.  It  is  probable,  as  M.  Bee  as- 
serts, that  this  substance,  like  lead,  forma  an  albuminate  of  mercury 
both  in  the  blood  and  the  solid  parts  of  the  body.  Bey ond  this  fact 
we  have  nothing  except  the  gross  alterations  found  in  the  stomach,  the 
kidneys,  and  other  organs,  when  mercury  has  been  taken  into  the 
tern  in  large  enough  quantities  to  cause  death.  It  is  perhaps 
necessary  to  say  that  the  accounts  which  have  been  given  of  metallic 
mercury  being  found  in   globules  in  the  brain  and  other  oi  not 

correct. 

A  curious  circumstance,  which  has  sone  is  the 

occurrence  of  salivation  in  the  cases  of  persons  who  have  taken  mercu- 
ry, but  who  have  not  exhibited  any  indications  of  hydrargysm  previous 
to  the  administration  of  iodide  of  potassium.     It  appears  that  the  i 
cury  set  free  from  its  albuminate  compounds  is  enabled,  while  trai 
ing  the  system  in  its  exit  through  the  kidney  it  a  toxia  power. 

I  have  never  witnessed  cases  of  the  kind,  and  they  must  be  rare.      It 
will  be  recollected  that  a  like  action  is  claimed  for  had. 

Treatment. — The  special  means  of  treatment  consists  in  the  free  ad- 
ministration of  the  iodide  of  potassium  in  accordance  with  the  discovery 
of  A  I.  Melsens,  already  alluded  to.     Under  the  action  of  this  remedy 
the  symptoms  of  hydrargysm   speedily  disappear,  and   the  patient 
gains  his  normal  or  almost  his  normal  condition.     The   worst 
the  affection  that  has  come  within  my  experience,  was  that  of  a  1 
Lng-glass  maker  of  this  city,  in  whom  the  tremor  and  other  evidi 
of  cachexia  were  exceedingly  striking.     He  was  unable  to  write,  from 
paralysis,  and  barely  able  to  shuffle  about  bis  room.     J  gave  hi 
once  thirty  grains  of  the   iodide  a  day,  in  divided  n  1  in  tie- 

course  of   a  week  doubled  the  quantity.     He  immediately  I 
mend,  and  was  well  in  less  than  five  weeks. 

Of  course,  while  under  treatment  the  patient  must  not  1"'  sub 
to  continual  poisoning  from  mercury. 

Tonics — iron,  quinine,  and  Btrychnia — are  useful  adjunota. 


CHAPTER   V. 

i 


The  Symptoms  indicative  of  slow  p  rally 

quite  oha  io.     'I  I" 

throat  and  stomach,  colicky  pains,  v  the  limbs, 

morrhage  from  the  uostrils,  puffim  is  of  tl  ially 

about  the  epileptiform 


924  TOXIC  DISEASES  OF  TEE  NERVOUS  SYSTEM. 

in  the  joints  and  contractions  of  the  fingers  and  toes,  numbness  some- 
times amounting  to  complete  anaisthesia,  and  paraplegia. 

In  addition  there  are  sometimes  ophthalmia  and  various  papular  and 
vesicular  eruptions  on  the  skin. 

Death  is  the  almost  inevitable  consequence  if  the  exposure  to 
toxication  continues,  or  speedy  relief  be  not  afforded  by  medical  treat- 
ment. 

The  Causes  of  arsenical  cachexia  are,  like  those  of  lead  and  mercury, 
to  be  found  generally  with  those  whose  occupation  requires  exposure 
to  contact,  through  the  lungs,  skin,  or  alimentary  canal,  with  arsenical 
preparations.  It  is  thus  met  with  in  furriers,  who  use  arsenious  acid  as 
a  preservative;  in  taxidermists,  who  employ  it  for  a  like  purpose;  in 
naturalists,  who  sprinkle  it  over  their  zoological  specimens,  and  who  in 
handling  them  absorb  the  powder  through  the  lungs ;  in  the  manufact- 
urers of  paper-hangings ;  in  dressmakers,  who  are  obliged  to  handle 
green  tarlatan  ;  in  makers  of  artificial  flowers,  and  in  the  workers  in 
chemical  manufactories,  where  arsenical  preparations  are  made;  and  in 
those  who  labor  in  arsenic-mines. 

It  has  also  occurred  in  persons  occupying  rooms  hung  with  the  brill- 
iant green-velvet  paper  into  the  manufacture  of  which  arsenic  enters 
in  large  quantities. 

Notwithstanding  the  general  susceptibility  of  mankind  to  the  dele- 
terious influence  of  arsenic,  it  appears  that  the  system  may  become  so 
habituated  to  its  use  as  actually  to  thrive  under  it.  This  is  the  case 
with  the  arsenic-eaters  of  Styria,  who  take  habitually  from  two  to  four 
or  five  grains  daily,  and  who,  nevertheless,  are  extremely  healthy,  and 
even  rugged-looking  people. 

The  Diagnosis  is  not  a  matter  of  difficulty,  especially  if  the  clinical 
history  be  inquired  into,  and  the  Prognosis,  except  in  extreme  cases,  is 
not  unfavorable  after  the  patient  is  removed  from  further  contact  with 
arsenic. 

The  Morbid  Anatomy  and  Pathology,  so  far  as  the  nervous  system 
is  concerned,  are  not  known,  and  except  in  acute  cases  of  arsenical 
poisoning,  with  which,  however,  we  are  not  now  concerned,  there  are  no 
definite  lesions  discoverable  in  other  parts  of  the  body. 

The  Treatment  consists  in  removing  the  patient  from  further  expos- 
ure, and  subjecting  him  to  the  most  favorable  hygienic  influences,  the 
strength  being  maintained  by  tonics.  If  there  are  contractions  of  anv 
of  the  limbs,  passive  motion,  frictions,  and  electricity,  are  indicated. 


INDEX 


r.M.r 
Abdominal  sympathetic,  pathology  of. . .  865 

Abscess,  chronic  cerebral 

Acromegaly 878 

symptoms 878 

prognosis 879 

morbid  anatomy  and  pathology 879 

treatment 880 

Active  cerebral  congestion 

varieties  of 32 

symptoms. .    33 

causes 68 

diagnosis 58 

prognosis 

morbid  anatomy 

pathology 

treatment ,;t 

Acute  alcoholism; 901 

symptoms 901 

Acute  ascending  paralysis 

symptoms 



diagnosis 

869 

and  pathol 

treatment 

iti* 819 

symptoms 819 

816 

"JIT 

'.'17 

morbid  anatomy 

pathology 816 

dent 819 







Acute  neuritis 

symptoms 




Acute  m  



morb 

treatment 

rtiul  myditis 4'M 

symptoms 481 

causes 

diagnosis 

prognosis 

!ii<>ri>i<l  anatomj  and  ;    ■ 

.'■nt 

inal  meningitis 

Acute  spinal  meningitis,  sj  mptoma 413 

i 

Agraphia 

Hi 

sj  mptoma 



diagnosis ; 



iii<>rl>i.  1  anatomj  and  | 

treatment 

Alcohol 

Alcoholism,  chronic 
Alternal 
Amyotrophic 



■ 
' 


926 


INDEX. 


PAGE 

Anmmift    of  antero-lateral    columns    of 

cord,  prognosis 399 

morbid  anatomy  and  pathology 400 

treatment 404 

Anaesthesia,  lead 890 

Anaesthesia,  neural S'-'A 

Anaesthesia,  of  cutaneous  nerves 834 

symptoms 834 

causes 836 

diagnosis 836 

prognosis 836 

morbid  anatomy  and  pathology 837 

treatment 837 

Anaesthesia  of  fifth  pair 837 

symptoms 837 

causes 838 

Anaesthesia  of  lit'th  pair,  diagnosis 838 

pr<  iguosis 838 

morbid  anatomy  and  pathology 838 

treatment 838 

Anapeiratic  paralysis 784 

symptoms ; 785 

causes 787 

diagnosis 788 

prognosis 788 

morbid  anatomy  and  pathology 788 

treatment 788 

Ankle  clonus 550 

Anterior  and  poBterii  >r  tracts  of  gray  mat- 
ter, inflammation  of 534 

Anterior  columns,  inflammation  of. 548 

Anterior  polio-myelitis 438 

Anterior  tract  of  gray  matter,  inflamma- 
tion of 437 

Antero-lateral  columns  of  the  cord,  anae- 
mia of 397 

Aphasia 182 

Apraxia 202 

Arseuicism 923 

symptoms 923 

causes 924 

diagnosis 924 

prognosis 924 

morbid  anatomy  and  pathology 924 

treatment '■'- ' 

A'thetosis 315 

morbid  anatomy  and  pathology 321 

treatment 325 

phy,  neural 317 

Atrophy  of  the  cerebellum 354 

Basilar  meningitis,  chronic 281 

ii,  syphilis  of 325 

Brain,  tumors  of. 296 

Bromism 915 

symptoms 91  5 

causes 919 

diagnosis 919 


PAGE 

Bromism,  prognosis 919 

morbid  anatomy 919 

treatment 921 

Capsule,  internal 339 

<  'atalepsy 742 

symptoms 743 

causes 748 

diagm  isis 748 

prognosis 749 

morbid  anatomy  and  pathology 749 

treatment 751 

Centrum  ovale,  lesions  of. 362 

Cerebellar  diseases 348 

hemorrhages 353 

symptomatology  of 348 

Cerebellar  peduncles,  lesions  of. 357 

Cerebellum,  atrophy  of 354 

Cerebellum,  lesions  of. 356 

Cerebellum,  tumors  of 351 

Cerebral  abscess 265 

Cerebral  anaemia 70 

symptoms 70 

causes 73 

diagnosis 75 

Cerebral  anaemia,  prognosis 75 

morbid  anatomy 76 

pathology 76 

treatment 77 

Cerebral  anaemia,  partial  132 

Cerebral  arteries,  embolism  of 142 

Cerebral  arteries,  thrombosis  of. 132 

Cerebral  blood-vessels,  obliteration  of. . .  132 
Cerebral  capillaries,  embolism  and  throm- 

bosis  of 154 

Cerebral  and  cerebellar  peduncles,  lesions 

of 347 

Cerebral  congestion 32 

Cerebral  congestion,  active 32 

< '.  rebral  congestion,  passive 53 

Cerebral  haemorrhage 80 

symptoms 81 

es 93 

diagnosis 96 

prognosis 100 

morbid  anatomy 101 

pathology 105 

differential  diagnosis Ill 

treatment 118 

Cerebral  hypcraemia 33 

Cerebral  meningeal  haemorrhage 124 

symptoms 124 

causes 126 

diagnosis 127 

prognosis 127 

morbid  anatomy  and  pathology 128 

treatment 1 30 

Cerebral  meningitis,  acute 212 


INDEX. 


FAfiK 

Cerebral  meningitis,  chronic 'j-.'l 

Cerebral  softening 161 

symptoms l  >;  i 

causes 168 

diagnosis 

prognosis 17" 

morbid  anatomy 1 70 

pathology 17- 

treatraent 1 7-i 

Cerebral  Bclerosis,  diffuse  1 .71 

•ral  syphilis 

bria 

Cerebritis 

Cerebrc-spinal  •                 041 

;"al  hypertrophic  pachymeningitis..  .-117 

Cervical  sympathetic,  pathology  of. 851 

i — brachial  neuralgia 

ico-occipital  neuralgia 

<  Jhorca 

Bymptoms 71" 

causes 7 1  8 

diagnosis 717 

prognosis  Tib 

moi bid  anatomy  and  pathology 1\^ 

ment T-'l 

Chronic  alcoholism 

symptom- 

<  !bronic  basilar  meningitis 

tymptoms 

diagnosis 240 

prognosis 240 

morbid  anatomy 241 

pathology 248 

menl -17 

<  'hronks  cerebral  

Chronic  cerebral  meningitis 221 

Chronic  neuritis 

nymptoms 







•  1  anatomy  and  patbol 

treatment  

Chronic  spinal  n  -lit 

symptoms -ill 



diagnosis 416 

prognosis 

morbid  anatomy  and  , 

rit 








r,  inflamm;i'  548 



Columi                                              .   in- 
flao  

Colni  548 

•ral 

.   mural 

.; 







prognosis 

treatment 

- 





'  

of 

!  neuralgia 



tymptoms 











tern 

! 

I 



928 


INDEX. 


PAGE 

Embolism  of  cerebral  arteries,  causes. . . .  145 

diagnosis 145 

prognosis 147 

morbid  anatomy  and  pathology 147 

treatment 149 

Embolism  of  cerebral  capillaries 154 

Embolism,  fat 157 

Embolism,  pigment 155 

Encephalitis,  suppurative 259 

Epilepsy 663 

symptoms 663 

causes 678 

diagnosis 680 

prognosis 681 

morbid  anatomy 681 

pathology 683 

treatment 692 

Exophthalmic  goitre 789 

symptoms 789 

causes 795 

diagnosis 795 

prognosis 796 

morbid  anatomy  and  pathology  ....  796 

treatment 799 

Facial  atrophy,  progressive 519 

Facial  paralysis 821 

symptoms 821 

causes 825 

diagnosis 825 

prognosis 825 

morbid  anatomy  and  pathology 826 

treatment 826 

Facial  spasm 831 

symptoms 831 

causes 831 

diagnosis 832 

prognosis 832 

morbid  anatomy  and  pathology 832 

treatment 832 

Fat  embolism 157 

Festination 288 

Fifth  pair,  anaesthesia  of 837 

Fifth  pair  of  nerves,  neuralgia  of. 839 

General  acute  myelitis 429 

Glosso-labio-laryngeal  paralysis 478 

symptoms 479 

causes 485 

diagnosis 485 

prognosis 486 

morbid  anatomy  and  pathology 487 

treatment 494 

Goll,  sclerosis  of  columns  of. 597 

Haematoma  of  the  dura  mater 180 

symptoms 1 30 

causes 130 


PAOE 

Haematoma  of  the  dura  mater,  diagnosis.  130 

prognosis 131 

morbid  anatomy  and  pathology 131 

treatment 132 

Haemorrhage,  cerebellar 353 

Haemorrhage,  cerebral 80 

Haemorrhage,  cerebral  meningeal 1-4 

Haemorrhage,  spinal  meningeal 463 

Haemorrhage,  spinal 406 

Haemorrhage,  ventricular 343 

Hemianopsia 345 

Hcmicrauia 855 

Hemisphere,   paralysis  from    central   le- 
sions of 338 

Hydrargysm 921 

symptoms 921 

causes 922 

diagnosis 922 

prognosis 922 

morbid  anatomy  and  pathology 922 

treatment 923 

Hydrophobia 641 

symptoms 641 

causes 648 

diagnosis 651 

prognosis 653 

morbid  anatomy 654 

pathology 659 

treatment 661 

Hy peraesthesia,  lead 890 

Hyperesthesia,  neural 838 

Hysteria 727 

symptoms 727 

causes 736 

diagnosis 737 

prognosis 737 

Hysteria,  morbid  anatomy  and  pathology  738 

treatment 739 

Hystero- epilepsy 763 

symptoms 763 

causes 769 

diagnosis 769 

prognosis 769 

morbid  anatomy  and  pathology 769 

treatment 769 

Hysteroid  affections 742 

Infantile  spinal  paralysis 438 

BJ  in]  >toras 439 

SB 442 

diagnosis 442 

prognosis 443 

morbid  anatomy 443 

pathology 452 

treatment 454 

Inflammation  of  anterior  columns 548 

Inflammation   of  anterior  tract  of  gray 

matter 437 


INDEX. 


Inflammation  of  anterior  and  po.-f' 
tracts  of  gray  matter 

Inflammation 

Inflammation  of  lateral  pyramidal  tr. 

Inflammation  of  motor  cells 478 

Inflammati  rand  trophic  cell*. 

Inflammation  of  the  posterior  columns. 

Inflammation  of  posterior  tr:. 

matter 

Inflammation  of  the  spinal  eord 

Inflammation  of  trophic  celli 

rrhage  and  • 
i  iiLfit  i- 

Landry's  paralysis 868 

Lateral  columns  and  anterior  gray  mat- 
ter, inflammation  of 

al  pyramidal  tracts,  inflamraat 

amesthi  da 

Lead-colic 889 

symptoms 889 

Lead  encephalopathy 886 

Lead  hyperesthesia 890 

,       causes 

diagnosis 

prognosis 893 

morbid  anatomy  and  pathology 893 

tr.  atment 

Lead-paralysis 888 

otrum  ovale 

donclea  M7 

•ii-  ol  the  cortex  a  n  bri 

.•is  of  the  medulla  oblongata 

as  of  the  optic  thalamus 

the  p.  .us  Varolii 

iptic  tract! 

■I-  of  tubercula  quadrigemin 

L motor  ataxia 

Lnmb  iralgia 

f  

;.ral 819 

ohroi  

M.  ningitis,  ohroi 

Die  vcit'cular 

rheuo  

senile 815 

spinal 413 

ral 

line 

t  cells,  inflammati*  n  ol 

M  itor  and  trophic  cells,  Lnfl 
Uultiple  cerebro 

sj  mptoms 

. .  Tv" 

diagnosis 


Multiple  cerebro-epinal 



morbid  anatomj 



Multiple  neuritis 









morl 



Mult  

Muscular  ■trophy,  prog 



liyelil  aeral 

acute 

liyeli  ri'ud 

ta 

Bymptoma 



diagnosis 

■sis --1 

morbid  anatomy  and  patholo; 

treatment 



sympt  am 





prognosis '77 

id  anatomy  and  pathol 
ment 

f 



atn.pliy 

I 



■n 



888 




930 


INDEX. 


PAGE 

Neuralgia  of  fifth  pair  of  nerves,  diagnosis  811 

prognosis 841 

lumbo-abdominal 843 

treatment  of. 843 

Neuritis,  acute 806 

chronic 817 

multiple 815 

Non-inflammatory  softening  of  the  spinal 

cord 611 

symptoms Gil 

causes 614 

diagnosis 614 

prognosis 614 

morbid  anatomy  and  pathology 615 

treatment 615 

Nctlmagel's  symptomatology 355 

Obliteration  of  cerebral  blood-vessels...  132 

Optic  thalamus,  lesions  of 341,  360 

Optic  tracts,  lesions  of 345 

Organic  infantile  paralysis 438 

Pachymeningitis 130 

cervical 417 

Paralysis,  acute  ascending 868 

Paralysis  agitans 282 

symptoms 283 

causes 289 

diagnosis 290 

prognosis 291 

morbid  anatomy  and  pathology 291 

treatment 293 

Paralysis,  anapeiratic . .  784 

Paralysis  consecutive  to  central  lesions  of 

the  hemispheres 338 

Paralysis,  cortical 334 

Paralysis,  facial 821 

Paralysis,  infantile  spinal 438 

Paralysis,  glosso-labio-laryngeal 478 

Paralysis,  Landry's 868 

Paralysis,  neural 821 

Paralysis  of  radial  nerve 830 

Paralysis  of  sixth  nerve 830 

Paralysis  of  third  nerve 828 

Paralysis,  pseudo-hypcrtrophic 629 

Paralysis,  spinal,  of  adults 458 

Paralysis,  lead 888 

symptoms 888 

Paramyoclonus  multiplex 698 

Paraphasia 202 

Paretic  tremor 782 

symptoms 782 

causes 782 

diagnosis 783 

prognosis 783 

morbid  anatomy  and  pathology 783 

treatment 784 

Partial  cerebral  anaemia 132 


PAGE 

Passive  cerebral  congestion 53 

symptoms 53 

causes 55 

diagnosis 58 

Passive  cerebral  congestion,  prognosis. .     6" 

morbid  anatomy 61 

pathology 62 

treatment 64 

Pathology  of  abdominal  sympathetic 865 

Pathology  of  cervical  sympathetic 851 

Pathology  of  thoracic  sympathetic 863 

Peripheral  nervous  system,  diseases  of. .  803 

Pigment,  embolism 155 

Plumbism 886 

symptoms 886 

Polio-myelitis  anterior 438 

Pons  Varolii,  lesions  of 358 

Posterior  columns,  sclerosis  of. 567 

Posterior  tract  of  gray  matter,  inflamma- 
tion of 532 

Primary  symmetrical  lateral  sclerosis.. .  549 

symptoms 549 

causes 552 

diagnosis 552 

prognosis 552 

morbid  anatomy  and  pathology 552 

treatment 555 

Progressive  facial  atrophy 519 

symptoms 519 

causes 524 

diagnosis 524 

prognosis 524 

morbid  anatomy  and  pathology 525 

treatment 531 

Progressive  locomotor  ataxia 567 

symptoms 567 

causes 579 

diagnosis 579 

prognosis 580 

morbid  anatomy 580 

pathology 585 

treatment 591 

Progressive  muscular  atrophy 495 

symptoms 495 

causes 501 

diagnosis 509 

prognosis 510 

morbid  anatomy  and  pathology 510 

treatment 517 

Pseudo -hypertrophic  paralysis 629 

symptoms r»30 

causes 636 

diagnosis 636 

prognosis 637 

morbid  anatomy  and  pathology 637 

treatment 639 

Radial  nerve,  paralysis  of. 830 


INDEX. 


931 


PAOE 

Raynaud's  disease 

Reactions  of  degeneration 

Rheumatic  meningitis 214 

Sciatica 

symptoms 

causes BIO 

diagnosis 811 

Sciatica,]!  Ml 

morbid  anatomy  and  pathology 811 

treatment 812 

Sclerosis,  amyotrophic,  lateral  spinal.. 
Sclerosis  of  anterior  pyramidal  tra 

Sclerosis,  diffused  cerebral 271 

Sclerosis  of  lateral  pyramidal  tract 549 

rosJs,  multiple  cerebrospinal 77'' 

Sclerosis,  multiple  spinal 

Sclerosis,  neural -17 

Sclerosis,  primary  symmetrical  lateral...  549 

Sclerosis  of  posterior  columns 

Secondary  degeneration  of  spinal  cord  . .   605 

symptoms 

causes 608 

diagnosis 609 

aosis 609 

morbid  anatomy  and  pathology. . . 

treatment 610 

Senile  meningitis 816 

Sixth  nerve,  para!;,  sis  of 

Softening,  cerebral 181 

Softening,   non-inflammatory,  of  spinal 

cord 611 

ii,  facial 

neural 831 

inal  paralysis 

Spinal  aniemia 

Spill.:  D 

symptoms 

causes 867 



8Y0 

id  anatomy 870 

pathology 

'in-lit 

Spinal  cord,  ana  mia  of  i  unna 

of. 



minated  inflammation  ■•!'. 

Inflammation  of 

non-inflammatoi  j  of 611 

ration  of. 

syphilis  of 

tiini'irs  of 616 



Bymptora i",; 

es 

aosis 

progno  is 


v.\i.r. 
Spinal  hemorrhage,  morbid  anatomy  and 

pathol  ■  _•• 4ii 

treatment 412 

Spinal  irritati. in 

ry 

symptoms 



morbid  anatomy  and  \ 

diagnosis 

prognosis 

Spinal  irritation,  treatment 892 

Spinal  meningitis 413 

Spinal  paralysis,  infantile 43s 

Spinal  paralysis  of  adults j.-- 

symptoms 





prognosis 471 

morbid  an  ....  471 

treatment 

Suppurati  

B]  Iilptnms 



diagnosis 

prognosis 

morbid  anatomy  and  1 

treatment 

Symmetrica]  gangn  ne  ol  I 

symptoms 

morbid  anal  imj  an  1  pathol 

tnent 

Sympathetic  nervous  system,  dii 

Symptomatoli 

Sjmpton 

Syphilis,  cerebral 

S\  philis  of  the  peripheral  ni 

tern 

Syphili 

branes 

Syringomyelia 

symptoms 



diagnosis 



morbid  ana;  my  ond  | 





morl 
Third  11 


932 


INDEX. 


PAGE 

Third  nerve,  diagnosis 829 

prognosis 829 

morbid  anatomy  and  pathology 830 

treatment 8S0 

Thomsen's  disease 880 

Thoracic  sympathetic,  pathology  of 863 

Thrombosis  of  cerebral  arteries 132 

symptoms 133 

causes 130 

diagnosis 137 

Thrombosis  of  cerebral  arteries,   prog- 
nosis    137 

morbid  anatomy  and  pathology 137 

treatment 141 

cerebral  capillaries 159 

Thrombosis  of  cerebral  veius  and  sinuses.  149 

symptoms , 149 

causes 153 

prognosis 153 

diagnosis 154 

morbid  anatomy  and  pathology 154 

treatment 154 

Torticollis 832 

causes 833 

diagnosis 833 

prognosis 833 

morbid  anatomy  and  pathology 833 

treatment 833 

Toxic  diseases  of  the  nervous  system. . . .  886 

Treatment  of  neuralgia 843 

Tremor,  convulsive 698 


PAGE 

Trophic  cells,  inflammation  of. 494 

Tubercula  quadrigemina,  lesions  of.. .343,  360 

Tubercular  cerebral  meningitis 251 

symptoms 251 

causes 255 

diagnosis 256 

prognosis 256 

morbid  anatomy  and  pathology 257 

treatment 258 

Tumors 'of  the  brain 296 

symptoms 296 

causes 304 

diagnosis 305 

prognosis 307 

morbid  anatomy  and  pathology 307 

treatment 312 

Tumors  of  cerebellum 351 

Tumors  of  nerves 820 

Tumors  of  spinal  cord 616 

symptoms 616 

causes 621 

diagnosis 621 

prognosis 622 

morbid  anatomy  and  pathology 622 

treatment 622 

Tilrck,  columns  of 548 

Veins  and  sinuses,  cerebral,  thrombosis  of  149 

Word-blindness 201 

Word-deafness 201 


THE    END. 


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VAN  BUREN  (W.  II.).  Lectures  upon  Diseases  of  the  Rectum,  and  the  Sur- 
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WEBBER  (S.  G.).  A  Treatise  on  Nervous  Diseases:  Their  Symptoms  and 
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WELLS  (T.  SPENCER).    Diseases  of  the  Ovaries.     8vo.     Cloth,  $4.50. 

WORCESTER  (A.).     Monthly  Nursing.     Second  edition,  revised.     Cloth,  $1.25. 

WYETII  (JOHN  A.).  A  Text-Book  on  Surgery:  General,  Operative,  and  Me- 
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